Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT thorax. 
 
You asked the Plan to pre-approve a CT thorax (71270). You say that you want to make sure you are not 
developing cancer. The Plan denied your request. The Plan says that criteria indicates that a less than 6mm sub 
solid solitary nodule does not require further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT chest (71270). Our reviewer says 
that the CT is medically necessary. Our physician reviewer found a repeat chest CT scan is considered 
reasonable and medically necessary for this enrollee. This is not a situation of a solitary pulmonary nodule, and 
the size of the opacities is not specified. The differential diagnosis includes infection and various inflammatory 
conditions. It is reasonable to repeat the chest CT at this time to determine whether these abnormalities are 
resolving or worsening, especially if the enrollee remains symptomatic. The denial is overturned. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT chest (71270) have been met. Therefore, we decided that the Plan has to 
pre-approve a CT thorax.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current care hospital with shortness of breath related 
to COVID-19 pneumonia. The documentation does not support that the enrollee requires services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve the requested spinal fusion. You say that you believe that this should be 
approved to help with your pain. The Plan denied your request. The Plan says you must quit smoking for six 
weeks and prove it with lab testing in order for fusion to be considered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 requested spinal fusion. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found smoking is an established contraindication to spinal fusion. Therefore, this 
procedure is not reasonable at this time. 
 
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 requested spinal fusion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal fusion surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation for a diagnostic service provided by dentist 
or physician (D9310) provided on July 24, 2020. 
 
You asked the Plan to pay for the dental service. You say that you let the dental office know that you could not 
defray the cost of the checkup and possible treatment. You say that you are retired and on a limited income. 
You also say that you advised that the services would be covered. The Plan denied your request. The Plan says 
the consultation for a diagnostic service provided by dentist or physician is not listed as a covered service. The 
Plan also says that any services not listed are not covered. 
 
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 pay for the 
consultation for a diagnostic service provided by dentist or physician (D9310) provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an upright walker. 
 
You asked the Plan to pre-approve an upright walker. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an upright walker. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a past medical history of degenerative joint disease of the knees and back and 
bilateral carpal tunnel syndrome and are having difficulty walking. The documentation supports that you have a 
diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of an upright walker. The 
medical records document your mobility limitation and that you are safe to use the walker and that a standard 
four wheeled walker would likely exacerbate your carpal tunnel syndrome. Therefore, you meet criteria for the 
requested item. 
 
Review of the file shows that the plan uses Local Coverage Determination, LCD L33791 to support their 
denial. However, the LCD guidelines do not apply to the upright walker. Therefore, we are unable to use LCD 
L33791 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upright walker have been met. Therefore, we decided that the Plan has to 
pre-approve an upright walker.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental prophylaxis services (D1110) provided on 
December 24, 2019. 
 
You asked the Plan to pay for the dental prophylaxis services. You say that these services were necessary when 
you received them. The Plan denied your request. The Plan says the claim processed correctly according to 
your supplemental benefits. 
 
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. The Plan covers the dental 
prophylaxis services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. This appears to be the third dental cleaning you received in the 2019 
calendar year. Based on this information, we decided that the Plan's rules for coverage of the dental prophylaxis 
services have been exhausted. Therefore, we decided that the Plan does not have to pay for the dental 
prophylaxis services (D1110) provided on December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with COVID-19 and required intubation and dialysis. He underwent trach and PEG 
placement. He does not require services at the LTACH that are not already available at the current facility. 
There are no services at the LTACH that he requires that are not already available and covered at the current 
facility. The LTACH services are therefore 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the arthrocentesis and hyaluronan injection 
provided on July 30, 2020, and August 13, 2020. 
 
You asked the Plan to waive the cost for the arthrocentesis and hyaluronan injection. You say that the 
procedure was approved. You say that you were not expecting to owe such a high amount. The Plan denied 
your request. The Plan says the cost share applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered Part B drug and a $40 copayment for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other 
non-physician health care professionals in a specialist's office (as permitted under Medicare rules).  
 
You have been asked to pay a total of $1,060.92 for the arthrocentesis and hyaluronan injection.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
July 30, 2020 Arthrocentesis $100.68 $40 $40 
July 30, 2020 Hyaluronan Injection $2,452.32 20% $490.46 
August 13, 2020 Arthrocentesis $100.68 $40 $40 
August 13, 2020 Hyaluronan Injection $2,452.32 20% $490.46 
TOTAL:    $1,060.92 
 
The arthrocentesis falls within the "Medicare Part B Prescription Drugs" benefit category. The hyaluronan 
injection falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost for the arthrocentesis and hyaluronan injection provided on July 30, 
2020, and August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram and does not 
have to waive the deductible and copayment for the excision of a breast lesion provided from June 15, 2020, to 
June 25, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram and to waive the deductible and 
copayment for the excision of a breast lesion. You say that you disagree with the charges. The Plan denied your 
request. The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for X-rays. Your contract with the Plan also clearly says that you must pay a $1,000 deductible for 
outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says 
that after the $1,000 deductible has been met, enrollee's must pay a $350 copayment for outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers. 
 
 
 
You received a diagnostic mammogram on June 15, 2020. Therefore, you are responsible to pay the $50 
copayment.  
 
You received the excision of a breast lesion on June 25, 2020. The excision of a breast lesion is considered an 
outpatient surgical procedure. The record shows that you had paid $0 toward the $1,000 deductible. Now that 
the deductible has been met, you are also responsible to pay a $350 copayment. The total amount you owe is: 
$1,350.  
 
The total amount you owe is: $50 + $1,350 = $1,400. 
 
You have been asked to pay the total amount of $1,400 for a diagnostic mammogram and the excision of a 
breast lesion. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. The excision of a breast lesion falls within the outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a diagnostic mammogram and does not have to waive the deductible 
and copayment for the excision of a breast lesion provided from June 15, 2020, to June 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (aflibercept). 
 
You asked the Plan to pre-approve Eylea. You say that the enrollee's plan does not require step therapy for 
Avastin. You also say that Eylea has not been denied in all of 2020. The Plan denied your request. The Plan 
says Eylea is subject to step therapy. The Plan says that Eylea is not the preferred drug. The Plan also says that 
Eylea is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that the drug 
is not medically necessary. Our physician reviewer found that treatment with Eylea is not medically necessary 
in this case because there is medical evidence that it is equivalent to bevacizumab (Avastin) in the enrollee's 
case. The reviewer found that the provided documentation shows the enrollee has diabetic macular edema with 
visual acuity of 20/25 in the right eye. The reviewer found that Eylea would only be considered superior to the 
plan's recommended alternative (bevacizumab) in the case of diabetic macular edema with visual acuity worse 
than 20/50. The reviewer found there is evidence in the medical literature that Eylea is equivalent to Avastin 
(bevacizumab) when visual acuity is 20/50 or better, but superior with poorer central acuity. Therefore, the 
reviewer found it is not medically necessary for the enrollee to be treated with aflibercept over bevacizumab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (aflibercept).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you are at risk for fractures. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that the enrollee has a 
diagnosis of osteoporosis. She has not tried and failed the Plan's required drug, zoledronic acid. The records do 
not show that she has a condition that would not allow her to take the required drug or that it would be less 
effective. The Prolia is therefore not reasonable or medically necessary at this time. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve the transportation. You say that you do not have a way to get to your 
appointments. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the transportation have not been met. Routine transportation services 
are not a covered benefit under your plan. Therefore, we decided that the Plan does not have to pre-approve 
routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out of network 
dental provider. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's dentist used to participate 
with the Dental Plan. You say that the dentist only recently became non-participating. You also say that the 
enrollee would like to continue to see this provider. The Plan denied your request. The Plan says dental 
services that you receive out of network are not covered. The Plan says that there are in network dental 
providers available to provide the requested services. 
 
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 
dental services to be provided by an out of network dental provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 30. 
 
You asked the Plan to pre-approve the core build up. You say that the services are necessary. The Plan denied 
your request. The Plan says core build up is not listed as a covered service. 
 
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 
crown (D2740) and core build up (D2950) for tooth # 30.