Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, other peripheral nerve 
or branch (64640). 
 
You asked the Plan to pre-approve the procedure. You say that the records should support the necessity of the 
services in dispute. The Plan denied your request. The Plan says the medical necessity 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 the procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is considered experimental/investigational.  It's role in the treatment of knee 
arthritis is still being considered.  Therefore, the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, other peripheral nerve or branch (64640).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trabectedin, Nivolumab, and Ipilimunab. 
 
You asked the Plan to pre-approve Trabectedin, Nivolumab, and Ipilimunab. You say that the requested 
Trabectedin, Nivolumab, and Ipilimunab are medically necessary. The Plan denied your request. The Plan says 
the requested Trabectedin, Nivolumab, and Ipilimunab are 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 Trabectedin, Nivolumab, and 
Ipilimunab. Our reviewer says that the requested Trabectedin, Nivolumab, and Ipilimunab are not medically 
necessary. Our physician reviewer found the requested regimen is not compendia supported, nor FDA 
approved. The literature provided is an abstract and cannot be the basis for approval. There would need to be a 
phase II/III published article which this is not. The requested regimen is not 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 Trabectedin, Nivolumab, and Ipilimunab have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Trabectedin, Nivolumab, and Ipilimunab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 18, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you saw this dentist for the first 
time because you wanted a second opinion to see if the procedure your former dentist wanted you to have was 
necessary. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 27, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of skin substitutes. 
 
You asked the Plan to pre-approve application of skin substitutes. You say that the requested application of 
skin substitutes is medically necessary. The Plan denied your request. The Plan says the requested application 
of skin substitutes 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 application of skin substitutes. Our 
reviewer says that the requested application of skin substitutes is not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that the application of two 
different skin substitutes (Q4158- Kerecis omega3 and Q4133- Grafix prime) at issue in this case meets 
Medicare criteria for medically reasonable and necessary per Social Security Act, Section 1862(a)1(A). 
Provided records do not document failure of wound healing with conventional treatment and the wound 
vacuum device. Her measured wound volume has declined from 15.08 cubic centimeters (cc) on July 8, 2022, 
to 7.84 cc on July 22, 2022, which is the latest record available. Records also do not explain the necessity of 
two different skin substitutes (Q4158- Kerecis omega3 and Q4133- Grafix prime) as opposed to one.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of application of skin substitutes have not been met. Therefore, we decided that the 
Plan does not have to pre-approve application of skin substitutes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam 
radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton 
beam radiation therapy 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 proton beam radiation therapy. Our 
reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician 
reviewer found based upon the provided records it is not plausible that proton therapy would provide a 
clinically meaningful benefit over a well-designed Intensity-modulated radiation therapy (IMRT) plan. I would 
therefore say that while not experimental, its potential benefit over non-proton-based radiation is an 
investigational question. Thus, proton therapy is not necessary as it would not meet the American Society for 
Therapeutic Radiology and Oncology or National Comprehensive Cancer Network (NCCN) criteria and 
therefore would not be furnished in accordance with accepted standards of medical practice. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) tooth #20, 22, 24, 27 and 29, and therapeutic parenteral drugs, two or more administrations (D9612). 
 
You asked the Plan to pre-approve surgical placement of implant body: endosteal implant (D6010) tooth #20, 
22, 24, 27 and 29 and therapeutic parenteral drugs, two or more administrations (D9612). You say that you 
would like the authorization for dental procedure to be approved. The Plan denied your request. The Plan says 
this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
surgical placement of implant body: endosteal implant (D6010) tooth #20, 22, 24, 27 and 29, and therapeutic 
parenteral drugs, two or more administrations (D9612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory molecular pathogen panel provided to the 
enrollee on December 28, 2021. 
 
You asked the Plan to pay for these services. You say that you believe the charges are appropriate for the level 
of acuity and intensity for the medical services provided. You are requesting reconsideration of payment on this 
claim. The Plan denied your request. The Plan says multiplex panels of six or more pathogens are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex polymerase chain reaction (PCR) 
respiratory viral panels of 6 or more pathogens are non-covered.  
 
Too many pathogens were tested to make this panel coverable by Medicare. 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 pay for a respiratory molecular pathogen panel provided to the enrollee on December 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal 
(D2751) for tooth #11. 
 
You asked the Plan to pre-approve the crown for tooth #11. You say that you received a root canal in tooth #10 
and #11 and you are now having pain in those teeth. The Plan denied your request. The Plan says x-rays show 
that a crown is not needed to fix your teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that a 
crown is not medically necessary for tooth #11. Our physician reviewer found that documentation indicates that 
tooth #11 does not exhibit significant coronal breakdown due to caries or fracture to warrant a crown 
restoration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a crown - porcelain fused to predominantly base metal (D2751) for tooth #11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system, phone holder, and 
specialty joystick handle. 
 
You asked the Plan to pre-approve power seat elevation system, phone holder, and specialty joystick handle. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested 
items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the power seat elevation system is not a covered 
benefit. The rules also say that for equipment to be covered, it must primarily serve a medical purpose.   
 
We looked at the file and Medicare rules. The requested power seat elevator is specifically not covered. The 
requested phone holder 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. Review 
of the file shows that the requested specialty joystick handle is for an additional joystick handle with a head 
array. This item exceeds the enrollees needs. There is no documentation in the file that supports that this item 
is needed for the enrollees medical needs. 
 
Based on this information, we decided that Medicare rules for coverage of power seat elevation system, phone 
holder, and specialty joystick handle have not been met. Therefore, we decided that the Plan does not have to 
pre-approve power seat elevation system, phone holder, and specialty joystick handle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prescription eye drops (Prolensa) purchased on March 
18, 2022. 
 
You asked the Plan to pay for Prolensa. You say that this claim was for prescription eye drops that were 
required following cataract surgery. The Plan denied your request. The Plan says Prolensa is not covered under 
your contract under any normal circumstances. The Plan also says that Prolensa is a prescription medication 
and is only obtainable as a prescription. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Prolensa is a prescription drug that is not included under the Plan's benefit reimbursement 
program. Therefore, we decided that the Plan does not have to pay for the prescription eye drops (Prolensa) 
purchased on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures (D5110) and lower partial 
dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 2, 2018. Therefore, 
we decided that the Plan does not have to pre-approve complete upper dentures (D5110) and lower partial 
dentures (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Functional Electrical Stimulator. 
 
You asked the Plan to pre-approve the Functional Electrical Stimulator. You say that the device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for the use of Functional Electrical 
Stimulation is limited to spinal cord injury patients for walking, who have completed a training program which 
consists of at least 32 physical therapy sessions with the device over a period of three months. 
 
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 Functional Electrical Stimulator. 
Our reviewer says that the requested device is not medically necessary. Our physician reviewer found the 
enrollee is not noted to be ambulatory secondary to their spinal cord injury. The requested device is not being 
used for ambulation and rather is being used for exercise. 
 
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 Functional Electrical Stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Functional Electrical Stimulator.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a consultation-diagnostic service (D9310),  intraoral-periapical 
first radiographic image (D0220), and intraoral-periapical each additional radiographic image (D0230). 
 
You asked the Plan to pre-approve the consultation and radiographic images. You say that this is not a 
duplicate claim. The Plan denied your request. The Plan says that you already received these services on July 1, 
2022. 
 
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. Specifically, the plan did not provide any medical records to support that its 
unnecessary for you to have another exam and radiographic images. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pre-approve a consultation-diagnostic service (D9310),  
intraoral-periapical first radiographic image (D0220), and intraoral-periapical each additional radiographic 
image (D0230).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on September 24, 2021. 
 
You asked the Plan to pay for the services. You say that you are appealing the denial of the services provided. 
The Plan denied your request. The Plan says that the agreement was limited to the surgical procedure 
performed and additional services would require an additional authorization. 
 
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. Specifically, there was insufficient information submitted to determine what 
services were billed. This means that we could not determine if the Plans rationale for why the services were 
denied is valid. Therefore, we decided that the Plan has to pay for the services provided on September 24, 
2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 5, 
2022, to April 10, 2022. 
 You asked the Plan to pay for SNF care. You say that SNF care was medically reasonable and necessary 
throughout the dates in question. The Plan denied your request. The Plan says SNF care was no longer 
medically necessary on the dates in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, the enrollee did not have documented 
skilled nursing needs. The enrollee did not have documented skilled therapy needs. The enrollee was 
functioning at her baseline. Daily skilled services were not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs were custodial and could have been, 
as a practical matter, provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 5, 2022, to April 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient level of care admission for percutaneous left 
atrial appendage closure. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the service is necessary. The Plan 
denied your request. The Plan says the information received by the Plan does not show you have complicated 
medical conditions. The Plan states percutaneous left atrial appendage closure surgery, however, may be 
performed 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found this procedure is typically performed at a lower level of care (observation 
level of care) and the provided records did not describe the enrollee with complexities or unstable conditions 
that would warrant inpatient services upon completion of the proposed procedure. There was no indication that 
the enrollee will require hospital services that would likely cross two (2) 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient level of care admission for percutaneous left atrial appendage 
closure.