Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 13, 2020, to June 
16, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that it was not necessary for the enrollee's care to exceed two 
midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the records show that the enrollee presented to the emergency room on June 13, 2020, with rib 
pain.  She was evaluated and admitted to observation. In the appeal letter, the provider stated that the patient 
was appropriately ordered inpatient level of care for the management of pain related to metastatic bone lesions. 
Multiple diagnostic tests were ordered and completed and were consistent with osteolytic lesions in bilateral lip 
ribs, thoracolumbar spine, sacrum and iliac bones. She was discharged home on June 16, 2020, when 
considered medically stable. The review indicates that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from June 13, 2020, to June 16, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Optune device and transducers (E0766) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is the standard of care of GBM patients. 
The Plan denied your request. The Plan says that this is not covered for the treatment of recurrent GBM. 
 
The Plan must follow Medicare rules. Medicare rules say that TTFT will be denied as not reasonable and 
necessary for the treatment of recurrent GBM. 
 
We looked at the file and Medicare rules. The records show that the enrollee has recurrent GBM. 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 the Optune device and transducers (E0766) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal attendant services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered custodial care. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
Personal attendant services are not skilled services, and are generally considered custodial care. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve personal attendant services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neuro-oncology clinic for 
the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is needed for continued visits for MRI 
monitoring. The Plan denied your request. The Plan says the plan requires that enrollees use providers from the 
PCP's specialty network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network neuro-oncology clinic for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate lower partial denture (D5222) and an 
immediate upper partial denture (D5221). 
 
You asked the Plan to pre-approve the dental items. You say that you changed plans so that you would have 
better dental coverage. You say that a plan representative advised that you were 100% covered. You say that 
you there was a discrepancy in the information that you were provided. The Plan denied your request. The Plan 
says immediate partial dentures are not listed as covered 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 an 
immediate lower partial denture (D5222) and an immediate upper partial denture (D5221).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve dental extractions. 
 
You asked the Plan to pre-approve dental extractions. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 dental extractions. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the extraction of teeth meets the criteria for coverage of medical necessity since this treatment 
is needed prior to your heart valve surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dental extractions have been met. Therefore, we decided that the Plan has to 
pre-approve dental extractions.  
 
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve photodynamic therapy (96573). 
 
You asked the Plan to pre-approve photodynamic therapy. You say that your dermatologists feels you would 
greatly benefit from this treatment and will provide case studies confirming the advantages of this treatment. 
The Plan denied your request. The Plan says that the enrollee does not meet the MCG criteria for medical 
necessity. 
 
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 photodynamic therapy. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a single report in the literature about successful novel treatment of 
recalcitrant transient acantholytic dermatosis (Grover disease) using red light 5-aminolevulinic acid 
photodynamic therapy. The enrollee may be allowed to try it, since all other treatments have failed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of photodynamic therapy have been met. Therefore, we decided that the Plan has 
to pre-approve photodynamic therapy (96573).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0676) 
 
You asked the Plan to pay for the device. You say that this denial is incorrect. The Plan denied your request. 
The Plan says this is a preventive service. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
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 pay for an intermittent limb compression device (E0676)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 POV (K0800). 
 
You asked the Plan to pre-approve the POV. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says your needs can be met with a 
lesser device.
 
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 POV. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that you have a personal mobility deficit that impairs 
participation in MRADLs in the home. You ambulate in the home without an assistive device and appear to 
have good stability. Your mobility is currently helped by a rollator. The documentation reveals you have legal 
blindness and the requested POV would not be safe. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 POV (K0800).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided February 24, 2020, through 
February 26, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the 
services could have been rendered at an observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the member's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided February 24, 2020, through February 26, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 12, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says you did not request prior authorization from the Plan. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on June 12, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the root canal (D3320), core build up 
(D2950), and the COVID-19 cleanliness precautions (D1999) provided on June 10, 2020. 
 
You asked the Plan to pay the full amount for the root canal and the COVID-19 cleanliness precautions. You 
say that the customer service agents are not helpful as you cannot understand what they are saying. You say 
that you were advised, among other services, that 2 root canals and 2 crowns would be covered at 100%. You 
say that you thought the services involved in a root canal and crown would be covered too. The Plan denied 
your request. The Plan says root canals have a 70% coinsurance when you receive them in network. The Plan 
says that the COVID-19 cleanliness precautions are not listed as a covered service. The Plan also says core 
build up has a 70% in network coinsurance. 
 
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 and root canal and core build up are 
listed as covered services, they each have a 70% coinsurance when you receive these services in network. The 
record shows that the Plan paid the in network cost share for the core build up. Cost sharing amounts are a 
contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the 
COVID-19 cleanliness precaution is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay the full amount for the root canal (D3320), core build up (D2950), and the COVID-
19 cleanliness precautions (D1999) provided on June 10, 2020.  
 
Your complaint about the customer service representatives is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
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 routine transportation. You say that you would like reconsideration 
because you are unable to drive and need transportation to your medical follow-up 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 routine transportation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve routine transportation.
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 the services are 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. 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 review has determined that the enrollee does not require services at the LTACH 
that are not available at the acute care hospital where they are currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan tablets. 
 
You asked the Plan to pre-approve the Xifaxan tablets. You say that the enrollee has been suffering from 
abdominal pain with episodes of diarrhea and a diagnosis of IBS for many years. The Plan denied your request. 
The Plan says the medication falls under Part D coverage, but the enrollee has no Part D pharmacy benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan tablets.  
 
Benefits for the Xifaxan tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a reduction mammaplasty (19318). 
 
You asked the Plan to pre-approve the reduction mammaplasty. You say that you would like reconsideration 
because you have tried conservative therapy and surgery was recommended by your provider. The Plan denied 
your request. The Plan says that you do not meet Medicare coverage criteria for this service. 
 
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 the reduction mammaplasty. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have evidence of significant symptoms related to your macromastia that 
have affected adversely your ADLs.  Your conservative management has included conservative analgesia and 
physical therapy. This has occurred over a greater than 6 month period as the physical therapy notes date back 
to 2019 (in treatment of shoulder pain).  Your degree of resection planned is consistent with a significant breast 
reduction. 
 
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 reduction mammaplasty have been met. Therefore, we decided that the Plan 
has to pre-approve a reduction mammaplasty (19318).  
 
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.