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

We decided that the Plan does not have to pay for inpatient emergency services provided to the enrollee from
May 4, 2020 to May 5, 2020.
You asked the Plan to pay for the services. You say that there was no payment on this claim. The Plan denied
your request. The Plan says free-standing ER facilities are not eligible to bill Medicare.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
You are not eligible to bill Medicare. The plan did not pre-approve the services. 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 inpatient emergency services provided to the enrollee from May 4, 2020 to May 5, 2020.
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 enrollee is stable and ready for transfer to a LTACH. You also say that the enrollee requires services that are not available at a skilled nursing facility. The Plan denied your request. The Plan says transfer to a LTACH is not medically necessary at this time.

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 does not require services at the LTACH that are not already provided and available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Our physician reviewer also found that transfer to a lower level of care may be considered soon.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandibular bone graft to prepare the mouth for 
dentures. 
 
You asked the Plan to pre-approve dental surgery. You say that you are in excruciating pain because your 
dentures do not align and do not fit your mandible. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this service is not covered by the Plan's dental 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. 
 
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 
mandibular bone graft to prepare the mouth for dentures.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo 240 mg/24 mL intravenous solution. 
 
You asked the Plan to pre-approve Opdivo. You say that this request is for recurrent treatment with Opdivo. 
The Plan denied your request. The Plan says that you advised the enrollee is are using this drug along for first 
line treatment of advanced non-small cell lung cancer, known as squamous, which is not a medically accepted 
indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the requested drug is indicated for the treatment 
of patients with metastatic squamous non-small cell lung cancer (NSCLC) with progression on or after 
platinum-based chemotherapy. The reviewer found that the provided documentation supports that the requested 
drug is approved for the enrollee's diagnosis. Therefore the reviewer found that the requested drug 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 Opdivo have been met. Therefore, we decided that the Plan has to pre-approve 
Opdivo 240 mg/24 mL intravenous solution.  
 
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 pre-approve outpatient treatment to be provided by a urology 
specialist. 
 
You asked the Plan to pre-approve urology services. You say that this provider has been your cancer doctor for 
9 years, and you know him and are comfortable with him. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the Plan believes that treatment with an oncologist 
is more appropriate for your condition. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 urology services. Our reviewer says 
that you do not meet the Medicare criteria for treatment with the requested urologist instead of the Plan's 
recommended treatment with an oncologist. Our physician reviewer found your urologist discussed with you 
that he wanted you to see an oncologist for Eligard injections that are not available with the urologist. 
Regarding the need for Eligard, only an oncologist would be appropriate, therefore the Plan's denial is 
medically justified on the basis that it is offering adequate care to meet your medical needs through referral to 
an oncology specialist. There is nothing unique about your condition that would make it medically necessary 
for you to see the requested urology specialist. The Plan's recommended oncologist is preferred and would be 
the standard of care for administration of Eligard for your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urology services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve outpatient treatment to be provided by a urology specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infection control supplies (S8301) provided on March 11, 
2020. 
 
You asked the Plan to pay for the infection control supplies. You say that you would like reconsideration 
because these supplies were medically necessary. The Plan denied your request. The Plan says CPT code 
S8307 has a status code of I which is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S8301 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S8301 has a status indicator of I. This means that CPT code S8301 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the infection control supplies have 
not been met. Therefore, we decided that the Plan does not have to pay for infection control supplies (S8301) 
provided on March 11, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the right knee. 
 
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says that an MRI is not 
medically necessary. 
 
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. Although the Plan's denial was based on medical necessity, the Plan did not 
submit medical records with the case file. A requested for records was submitted to the Plan on October 13, 
2020, with no response. Without supporting records, the Plan's denial cannot be substantiated. Therefore, we 
decided that the Plan has to pre-approve an MRI of the right knee.  
 
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 a recliner chair for the enrollee. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a convenience item and not considered durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667 x2). 
 
You asked the Plan to pre-approve a pneumatic compressor and full leg segmental pneumatic appliances. You 
say that the items are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD is covered when specific criteria is met. 
 
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 pneumatic compressor and full leg 
segmental pneumatic appliances. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found while the enrollee is noted to have lymphedema, there is insufficient documentation to show 
that the enrollee has adequately used standard therapies (elevation, weight loss, exercise, massage, compression 
stockings) resulting in insufficient improvement (serial leg measurements).  As such, the requested items are 
not shown to be currently medically necessary or reasonable. 
 
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 pneumatic compressor and full leg segmental pneumatic appliances have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) 
and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve the hearing aids. You say that you would like reconsideration because the 
member is having trouble hearing even after the adjustments. The Plan denied your request. The Plan says 
Medicare does not cover hearing aids. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a mammography procedure of both breasts 
(77066) and a breast biopsy (19083) performed on November 5, 2019. 
 
You asked the Plan to waive the copayments for a mammography procedure and a breast biopsy. You say that 
the provider did not complete the procedure as specified. The Plan denied your request. The Plan says the 
correct copayments were applied. 
 
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 $200 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, and a $295 
copayment for Medicare-covered surgery.  
 
You have been asked to pay a $125.79 copayment for a mammography procedure. A mammography procedure 
falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. You 
have also been asked to pay a $295 copayment for a breast biopsy. A breast biopsy falls within the "Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers" benefit category. This means that you have been asked to pay less than or equal to 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 copayments for a 
mammography procedure of both breasts (77066) and a breast biopsy (19083) performed on November 5, 
2019.  
 
We read your letter and knows that you may have a quality of care concern. We cannot address quality of care issues. 
We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on April 
14, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the member's terminal 
condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on April 
14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 27, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says they are a secondary insurer. The Plan verified the enrollee was involved in an 
automobile accident in which the enrollee's automobile insurance is listed. As a Medicare secondary payer, a 
benefit is payable when the primary insurance payer's calculated amount is less than the Medicare allowed rate 
for the service. The primary carrier's payment of $352.02 is higher than the Medicare allowable fee maximum 
of $220.01. Therefore, the Plan is not required to make payment on this claim.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. The Plan has identified the primary 
insurer and confirmed you have been paid above the Medicare allowable for this type of service. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic 
appliance for use with pneumatic compressor, full leg. 
 
You asked the Plan to pre-approve a pneumatic compressor and full leg segmental pneumatic appliances. 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 follows Medicare rules. Medicare rules say that a PCD is covered when specific criteria has been met. 
 
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 pneumatic compressor and full leg 
segmental pneumatic appliances. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that you meet the coverage 
criteria as there is no documentation that the lymphedema extends onto the trunk, abdomen or chest. 
 
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 pneumatic compressor and full leg segmental pneumatic appliances have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor and 
segmental pneumatic appliance for use with pneumatic compressor, full leg.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) chest, a 
CTA Abdomen, or a CTA Pelvis. 
 
You asked the Plan to pre-approve a CTA chest (71275), a CTA Abdomen (74175), and a CTA Pelvis (72191). 
You say that the CTAs are medically necessary. The Plan denied your request. The Plan says your last CT 
chest scan was unremarkable and there is no noted abdominal aorta aneurysm rupture related symptoms or an 
evaluation. 
 
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 CTA chest (71275), a CTA Abdomen 
(74175), and a CTA Pelvis (72191). Our reviewer says that the CTAs are not medically necessary. Our 
physician reviewer found a CT angiogram of the chest was completed a few months prior showing no evidence 
of a pulmonary embolism (PE). A request for CTA chest/abdomen/pelvis was made by the family doctor based 
on the recent presenting complaints and history of PE and abdominal aneurysm. 
 
Surveillance of prior PE and abdominal aneurysm is being requested via CTA chest/abdomen/pelvis. However, 
the results of the prior abdomen and pelvis imaging were not provided to compare and CT chest was without 
signs of PE from a few months ago. Also, recent clinical presentation did not suggest signs or symptoms of PE 
or aneurysm rupture to justify the testing urgently. Therefore, this request for CTA chest/abdomen/pelvis will 
be considered not 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 a CTA chest (71275), a CTA Abdomen (74175), and a CTA Pelvis (72191) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography 
angiography (CTA) chest, a CTA Abdomen, or a CTA Pelvis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve the inpatient care. The Plan denied your request. The Plan says medical 
records were not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that 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.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain records from the 
provider. The Plan made several attempted to obtain these records without response from the provider. Without 
medical records to determine medical necessity, it cannot be confirmed that Medicare coverage criteria have 
been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandible bone graft. 
 
You asked the Plan to pre-approve mandible bone graft. 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. 
 
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. Review of the file does not support severe atrophy. Therefore, we 
decided that the Plan does not have to pre-approve mandible bone graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs this. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered and 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The requested item is not covered under Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of a total electric hospital bed have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).