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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. There is no documentation of medically instability, and the documentation does not support 
that the enrollee has complex medical issues that require acute rehab nursing care, or monitoring by an 
inpatient Physical Medicine and Rehabilitation (PM&R) physician three (3) times per week. While the enrollee 
is reasonably expected to benefit from continued physical therapy (PT) and occupational therapy (OT), the 
documentation does not support that there is need for an intensive therapy program with therapy 3 hours per 
day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. There is a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit and related services provided on October 
22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit and related services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
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 rest home visit and related services provided 
on October 22, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says bone replacement graft for 
ridge preservation with dental code D7953 is not covered by Medicare or the Plan's supplemental dental 
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 bone 
replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on May 26, 2020. 
 
You asked the Plan to pay for the vision services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network optical provider. 
 
We looked at the file and the Plan's rules. Review of the file shows that you received the vision services by an 
out of network provider. The plan only covers vision services when provided by a network optical provider. 
Based on this information, we decided that the Plan's rules for coverage of the vision services have not been 
met. Therefore, we decided that the Plan does not have to pay for the vision services provided on May 26, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-rays provided on February 24, 2020. 
 
You asked the Plan to pay for the office visit and x-rays. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit and x-rays provided on February 24, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve Human Leukocyte Antigen (HLA) typing. 
 
You asked the Plan to pre-approve Human Leukocyte Antigen (HLA) typing. You say that the requested HLA 
typing is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet 
criteria for Human Leukocyte Antigen (HLA) typing. 
 
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 Human Leukocyte Antigen (HLA) 
typing. Our reviewer says that the enrollee does meet criteria for Human Leukocyte Antigen (HLA) typing. 
Our physician reviewer found the enrollee is with B cell ALL ph+ diagnosed on 8/17/20 currently on cycle 1A 
day 12 of HYPERCVAD with Dasatinib. Per NCCN guidelines ALL 1.2020, page ALL-4, for patients greater 
than 65 who respond, allogeneic treatment is allowed in appropriate candidates. Based on the documentation 
provided in this case, the enrollee meets criteria and the requested HLA typing is medically reasonable and 
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 Human Leukocyte Antigen (HLA) typing have been met. Therefore, we decided 
that the Plan has to pre-approve Human Leukocyte Antigen (HLA) typing.  
 
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 comprehensive oral evaluation provided on January 6, 
2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you are asking for 
reimbursement for the exam. The Plan denied your request. The Plan says the annual limit allowed by your 
dental plan for this benefit year has been paid. 
 
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, you also have an annual maximum of 
$500 every year for non-Medicare-covered preventive and comprehensive dental services. The Plan paid $500 
toward dental services provided on January 7, 2020 and January 13, 2020, which exhausted your benefit. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on 
January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta Xmg injection. 
 
You asked the Plan to pre-approve the injection. You say that you are requesting approval to treat the member 
with Zilretta for primary osteoarthritis. The Plan denied your request. The Plan says the member shows that 
they received Zilretta injections for both knees on March 12, 2020 and then again on July 9, 2020. The Plan 
states the FDA does not recommend repeat injections as the safety and efficacy of repeat injections of Zilretta 
have not been established. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the member shows that they received Zilretta injections for both knees on March 12, 2020 and 
then again on July 9, 2020. The Plan states the FDA does not recommend repeat injections as the safety and 
efficacy of repeat injections of Zilretta have not been established. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zilretta Xmg injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that the requested bone marrow aspiration 
is medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspiration is 
not medically necessary. 
 
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 bone marrow aspiration. Our reviewer 
says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the 
enrollee has chronic radicular back pain that has been progressively worsening. The Plan approved the 
requested spinal surgery with inpatient stay. However, bone marrow aspiration is experimental. More research 
is needed to show the safety and efficacy of the procedure. It is not needed for the approved 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 bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection of denosumab provided on 
May 15, 2020. 
 
You asked the Plan to waive the coinsurance for injection. You say that this injection is normally given to you 
at a clinic but due to the COVID-19 situation you were told to go to the hospital emergency room to receive it. 
The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct. 
 
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 injection. The allowed amount of this claim is $882.27, and you have been asked to pay a cost-
sharing amount of $169.67 which is less than 20% coinsurance for this injection. 
 
You have been asked to pay less than 20% coinsurance for injection. Injection falls within the Medicare Part B 
Prescription Drugs 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 coinsurance for an injection of 
denosumab provided on May 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laparoscopy hysterectomy procedure 
you had at an out-of-network ambulatory surgical center on May 20, 2020. 
 
You asked the Plan to waive the copayment for the procedure at an out-of-network ambulatory surgical center. 
You say that although you are aware that this facility was out-of-network, your doctor wanted to use this 
facility instead of the in-network facility due to scheduling issues because of COVID-19. The Plan denied your 
request. The Plan says you were charged this copayment 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 50% 
coinsurance for surgery services at an out-of-network ambulatory surgical center.  
 
You have been asked to pay 50% coinsurance for the procedure at an out-of-network ambulatory surgical 
center. This cost sharing applies regardless of the reason why you went to this facility. 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 the laparoscopy hysterectomy procedure you had at an out-of-
network ambulatory surgical center on May 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device (22869). 
 
You asked the Plan to pre-approve an interspinous and/or interlaminar device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 an interspinous and/or interlaminar 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the device is experimental. More research is needed to 
show safety and efficacy. 
 
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 interspinous and/or interlaminar device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 9, 2020. 
 
You asked the Plan to pay for the orthosis. 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-sacral orthosis (L0650) provided to the 
enrollee on April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided on 
May 20, 2020, and June 2, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedure (D1999). You say that these were listed on 
the statement as PPE. You say that since these were preventive measures they should be covered by insurance. 
The Plan denied your request. The Plan says the service is 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 pay for the 
unspecified preventive procedure (D1999) provided on May 20, 2020, and June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy. 
 
You asked the Plan to pre-approve tumor treatment field therapy. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval. 
 
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. The documentation confirms the enrollee has recurrent anaplastic 
astrocytoma. Tumor treatment field therapy is not reasonable and necessary for the treatment of recurrent 
disease. Based on this information, we decided that Medicare rules for coverage of tumor treatment field 
therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment 
field therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing wheelchair. 
 
You asked the Plan to pre-approve a standing wheelchair. You say that the requested item is necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a standing wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided (one office visit note of September 18, 2020) 
there is no documentation that supports that the standing wheelchair at issue in this case is medically 
reasonable and necessary. The note of September 18, 2020 reports that you are wheelchair-bound and you want 
to discuss a new wheelchair with the provider and that "other durable medical equipment" was ordered but no 
additional detail was provided with regard to the necessity of a standing wheelchair. 
 
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 standing wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a standing wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (62322). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the use of fluoroscopy or Computed 
Tomography (CT) is supported for needle guidance. 
 
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. Medicare guidelines state that procedure requirements for all 
methods of epidural steroid injections should be done with image-guidance. Fluoroscopy and CT are the only 
two validated imaging methods. The review shows you are requesting to use a method without imaging 
guidance. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (62322).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services you 
received on March 9, 2020. 
 
You asked the Plan to waive the copayment for the outpatient mental health services. You say that you have 
never been charged a copayment before and you do not have the means to pay this copayment. The Plan denied 
your request. The Plan says you were charged this amount 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 a $120 
copayment for outpatient mental health services provided at an outpatient hospital facility.  
 
You have been asked to pay a $120 copayment for the outpatient mental health services. The provider of these 
services billed as an outpatient hospital facility, so these services fall within the outpatient mental health 
services provided at an outpatient hospital facility 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 outpatient mental health services you received on March 9, 2020.