Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care 
and pre-approved care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s service. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build-up for teeth 5, 7, and 11, crown for teeth 5, 7, 
and 11, partial maxillary denture, and partial mandibular denture 
 
 
 
You asked the Plan to pre-approve core build-up, crowns, partial maxillary denture, and partial mandibular 
denture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Review of the file shows that you are requesting core build-up for teeth 5, 7, and 11. Core build-up is not a 
covered benefit. The requested crowns for teeth 5, 7, and 11 are non-covered because the documentation does 
not support significant breakdown due to decay or trauma. The requested partial maxillary and partial 
mandibular dentures are only covered once every 60 months. You previously received dentures. 
Sixty (60) months have not passed since you last received dentures.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build-up for teeth 5, 7, and 11, crown for teeth 5, 7, and 11, partial maxillary denture, and partial mandibular 
denture
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral knee orthoses (L1851) and suspension sleeves 
(L2397) provided. 
 
 
 
You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid. The Plan denied 
your request. The Plan says no claims were submitted for this member by the referring provider. The Plan 
states the member was contacted and stated that they have never heard of the company or received any items.  
The Plan states the member also confirmed they do not know the referring physician. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthoses and sleeves have not been met. There is no invoice or 
delivery slip which shows what was included in that delivery, and also, the date of service does not match 
either the date that the shipment was shipped (April 20, 2020) or when the item was delivered (April 24, 2020). 
Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1851) and suspension 
sleeves (L2397) provided.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve ILUMYA (J3245). 
 
You asked the Plan to pre-approve ILUMYA. You say that the medication is necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ILUMYA. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found there are limited options for this elderly 
enrollee with malignancy history and need to avoid immunosuppressants in light of pandemic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ILUMYA have been met. Therefore, we decided that the Plan has to pre-
approve ILUMYA (J3245).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venofer (J1756). 
 
You asked the Plan to pre-approve Venofer. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all drugs and biologicals used for the treatment 
of ESRD are included in the ESRD PPS and are not separately paid as of January 1, 2011.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Venofer have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Venofer (J1756).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the submitted records show that you had 
spine surgery on November 12, 2020. The physical therapy note on November 23, 2020 states that you need 
minimal assistance with standing up and walking 40 feet. You do not require the intensity of services provided 
at an IRF. You do not need 15 hours per week of rehabilitative services and regular physician evaluation. IRF 
services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 27, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 27, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to treat sacroiliac joint pain. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in a lot of pain. The Plan 
denied your request. The Plan says the service is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Radiofrequency ablation used for sacro-iliac joint pain is considered 
not medically necessary/investigational. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency 
ablation to treat sacroiliac joint pain.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the diagnostic radiology services provided on May 14, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has denied payment for the diagnostic radiology services provided on 
May 14, 2020 stating that the service was not billed with an appropriate diagnosis code. However, the Plan 
provided no documentation showing that Medicare will not pay for the diagnostic radiology services if 
submitted with the diagnosis code billed. We find that the Plan has not substantiated their reasoning for denial 
of payment for these services. Therefore, we decided that the Plan has to pay for the diagnostic radiology 
services provided on May 14, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (CALR, MPL, and JAK2 exon 12 
mutation analysis). 
 
You asked the Plan to pre-approve genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genetic testing. Our reviewer says that 
the documentation does not support that the requested genetic testing is medically reasonable or necessary. Our 
physician reviewer found the enrollee has iron deficiency anemia, hypercoagulable state, deep vein thrombosis, 
and increased red blood cell count. The provided documentation did not show evidence of a negative 
BCR/ABL or JAK2 V617F testing as required by the criteria prior to considering testing for JAK2 exon12 or 
CALR. The enrollee does have a diagnosis that meets the Medicare criteria for the above genetic testing, 
however, the testing will be considered not medically necessary as the sequence of testing was not followed as 
described above. JAK2 was positive and did not require any other testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (CALR, MPL, and JAK2 exon 12 mutation analysis).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental services (D7471, D9223).You asked the Plan to pre-approvethe dental services. You say that these services are medically necessary.The Plan denied your request. The Plan says the dental services requested are not listed as covered benefits under the enrollee's plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvedental services (D7471, D9223).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the arm sling (L3650). You say that you cannot obtain prior authorization at the 
time of service. The Plan denied your request. The Plan says prior authorization is required for non-network 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on June 26, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Therapy. 
 
You asked the Plan to pre-approve the Proton Beam Therapy. You say that Proton Beam Therapy is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Proton Beam Therapy is covered when medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Proton Beam Therapy. Our 
reviewer says that Proton Beam therapy is not medically necessary. Our physician reviewer found in this case it 
is not plausible that proton therapy could provide a clinically meaningful benefit over a well-designed IMRT 
plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Proton Beam Therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Proton Beam Therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for scheduled inpatient admission provided to the enrollee from 
December 6, 2019, to December 7, 2019. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan as it was 
medically necessary. The Plan denied your request. The Plan says this was a scheduled service for which there 
was no prior authorization. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that inpatient care requires prior authorization. The records do not show the enrollee had prior authorization.  
Therefore, we decided that the Plan does not have to pay for scheduled inpatient admission provided to the 
enrollee from December 6, 2019, to December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device. 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the device is necessary to 
prevent deep vein thrombosis. The Plan denied your request. The Plan says the documentation does not 
indicate services are necessary for treatment of the enrollee's condition. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to preapprove a pneumatic compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic parenteral drug injection (D9610), 
sedation - first 15 minutes (D9239), and sedation - each subsequent 15 minute increment (D9243 x3). 
 
You asked the Plan to pre-approve a therapeutic parenteral drug injection, sedation - first 15 minutes, and 
sedation - each subsequent 15 minute increment. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic parenteral drug injection (D9610), sedation - first 15 minutes (D9239), and sedation - each 
subsequent 15 minute increment (D9243 x3).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 7, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services 
provided by non-participating providers are excluded. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on November 7, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the opthalmology services (92004, 92250, 92015) provided 
on July 9, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON opthalmology services. You say that these services were originally billed 
to Medicare. The Plan denied your request. The Plan says these services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the opthalmology services (92004, 92250, 92015) 
provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar brace (L0457) provided to the enrollee on June 16, 
2020. 
 
You asked the Plan to pay for back brace. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's 
condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a lumbar brace (L0457) provided to the enrollee 
on June 16, 2020.