Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the limited oral evaluation and intraoral x-rays provided on February
15, 2020.
You asked the Plan to pay for the limited oral evaluation and intraoral x-rays. You say that the office informed
you they were in-network. You say that you are now left paying the bills. The Plan denied your request. The
Plan says that the provider or provider group is excluded from receiving payment.
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. We were not able to confirm that this provider is excluded by the Office of the
Inspector General (OIG) and we found that the provider has a current license. As such, the denial
rationale offered by the plan is not supported. Therefore, we decided that the Plan has to pay for the limited
oral evaluation and intraoral x-rays provided on February 15, 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.
Your complaint about not wanting to pay for this because the doctor made an error 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia - first 15 minutes 
(D9222) and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia - first 15 minutes and deep 
sedation/general anesthesia - each subsequent 15 minute increment. You say that the services are necessary. 
The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent 
15 minute increment (D9223).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular
physician evaluation. You will be limited by your weight bearing status for some time. Your care needs can be
met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a balloon sinuplasty. 
 
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 that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic sinusitis that has 
not improved with oral antibiotics, antihistamines, nasal sprays, and sinus irrigations. The requested balloon 
sinuplasty is the standard of care for recurrent sinusitis of the maxillary, frontal, and sphenoid sinuses. The 
services are reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a balloon sinuplasty.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Bevacizumab. 
 
You asked the Plan to pre-approve Bevacizumab. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
 
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 Bevacizumab. Our reviewer says that 
the documentation does support that the requested drug is medically reasonable and necessary. Our physician 
reviewer found the enrollee was diagnosed in 2006 with esthersioneuroblastoma with recurrences. The 
requested use of Bevacizumab is not FDA-approved for the enrollee's diagnosis, however, the requested use is 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. Moreno, L., et al. "Bevacizumab for children with relapsed & refractory high-risk neuroblastoma (RR-
HRNB): Results of the BEACON-neuroblastoma randomized phase II trial-A European ITCC-SIOPEN trial." 
Annals of Oncology 30 (2019): v901. supports the requested use. Therefore, the enrollee does meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bevacizumab have been met. Therefore, we decided that the Plan has to pre-
approve Bevacizumab.  
 
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 repairs for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC repair. You say that the PWC is necessary and these repairs are 
required. The Plan denied your request. The Plan says as the cost of repairs has exceeded the cost of 
replacement and the PWC is more than five years old, repairs cannot be approved at this time. Replacement is 
required. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs can only be covered up to the estimated 
cost of replacement.  
 
In this case, the Plan has covered $7089 in repairs for this PWC which is more than five years old. This is more 
than the estimated cost to replace this PWC. As such, no further repairs are covered, though replacement is an 
option if requested. Therefore, we decided that the Plan does not have to pre-approve repairs for a power 
wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor for the enrollee. 
 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the medical records do not indicate that any adjustments are needed at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the monitor. Our reviewer says that the 
requested monitor is considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee is compliant, and is already in a diabetic education program. The enrollee will benefit from 
continuous glucose monitoring and the documentation submitted is consistent with someone who would 
comply and benefit. The reasons for denial are not relevant in this case. 
 
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 monitor have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor for the enrollee. 
  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services, including physical therapy. 
 
You asked the Plan to pre-approve the home health services. You say that you believe that this should be 
covered in the home due to your condition. The Plan denied your request. The Plan says your doctor has 
indicated that you are not considered homebound and would be able to attend outpatient physical therapy. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. There is no statement from the provider certifying your 
homebound status and the Plan spoke to the ordering provider who stated you are able to leave the home to 
obtain outpatient services. Therefore, we decided that the Plan does not have to pre-approve home health 
services, including physical therapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) Computed Tomography 
(CT) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with records. The Plan denied 
your request. The Plan says that the denial of authorization for this service is correct, because this PET scan is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested PET scan. Our physician reviewer found the enrollee has 
a metastatic high grade undifferentiated pleomorphic sarcoma that involves her bones and disease in her 
extremities. A PET scan allows both imaging of her bones and her extremities to her thighs. A PET scan is 
being requested to determine the extent of disease to determine if systemic therapy is warranted. Therefore, this 
request 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a Positron Emission Tomography (PET) Computed Tomography (CT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the use of Grafix skin substitute for a non-healing 
wound. 
 
You asked the Plan to pre-approve the Grafix skin substitute. You say that the enrollee has had an open wound 
for 10 months and this treatment could be helpful in allowing healing. The Plan denied your request. The Plan 
says the criteria for this treatment are not 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 the Grafix skin substitute. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a diagnosis of diabetes mellitus with a chronic open wound resulting 
from wound dehiscence following a midfoot amputation in October 2019. Documentation supports the enrollee 
has had debridement, wound care and a wound vacuum. Documentation does not include a vascular 
examination, discussion of skin substitute, or rationale for treatment. Without the support of the documentation, 
Medicare approval cannot be determined. 
 
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 Grafix skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of Grafix skin substitute for a non-healing wound.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig for the enrollee. 
 
You asked the Plan to pre-approve a wig. You say that that the enrollee needs this for hair loss due to 
trichotillomania. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that the enrollee resides in a nursing facility and goes 
to this office for treatment. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an 
in-network provider. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Kenalog injection provided on February 25, 2020. 
 
You asked the Plan to pre-approve the Kenalog injection. You say that this should be covered due to the 
medical need for this treatment. The Plan denied your request. The Plan says the use of a steroid injection for 
treatment of this condition is not warranted without a trial of anti-histamines or intranasal steroids. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Kenalog injection. Our reviewer 
says that the Kenalog injection provided on this visit was not medically reasonable and necessary. Our 
physician reviewer found the patient in this case is a 73-year-old female who received a Kenalog injection for 
diagnosed allergic rhinitis on 2/25/2020. It was stated that her allergic rhinitis was a recurrent chronic problem 
and that she had tried oral decongestants without relief. The standard first line treatment options for allergic 
rhinitis are oral anti-histamines and intranasal steroids. There was no documentation that these medications had 
been tried and failed or were in some way contraindicated to justify a corticosteroid injection. Also, if a 
corticosteroid injection were to be justified, there was no indication that an oral corticosteroid would be 
contraindicated or less effective than the injection. The documentation does not support that the Kenalog 
injection was safe and effective for the patient compared to first line lower-risk medication options. 
 
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 Kenalog injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Kenalog injection provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hand x-ray (73130) provided on November 13, 2019. 
 
You asked the Plan to pay for a hand x-ray. You say that multiple tests were done. The Plan denied your 
request. The Plan says this service was paid on a previous claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional unit of CPT code 73130 is not supported in the medical record. The medical record 
only supports the 2 units of CPT code 73130 that were previously paid. Based on this information, we decided 
that Medicare rules for coverage of a hand x-ray have not been met. Therefore, we decided that the Plan does 
not have to pay for a hand x-ray (73130) provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine 
(90715) provided on February 21, 2020. 
 
You asked the Plan to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine. You say that you 
would like reconsideration because you were told you needed this service. The Plan denied your request. The 
Plan says the services performed are not covered under regular Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus, 
diphtheria toxoids and acellular pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus, 
diphtheria toxoids and acellular pertussis vaccine. Therefore, we decided that the Plan does not have to pay for 
a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) provided on February 21, 2020.  
 
Benefits for the tetanus, diphtheria toxoids and acellular pertussis vaccine 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan services. 
 
You asked the Plan to pre-approve the CT scan. You say that you have the basic human right to get required 
investigative treatments and follow-up of your cancer. The Plan denied your request. The Plan says the 
guidelines do not support the surveillance imaging of stage I colon and rectal adenocarcinoma. 
 
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 the CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found Cologuard testing was positive 
followed by diagnosis and treatment (TAMIS) in 2019. The enrollee is currently in surveillance. The NCCN 
guidelines recommend follow-up colonoscopy one year after treatment based on the most current evidence. CT 
imaging of multiple areas including the thorax, abdomen, and pelvis is not recommended by these guidelines. 
There were no special circumstances noted in the documentation to support the use of this extensive CT 
scanning 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) scan services.