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

 
We decided that the Plan does not have to pre-approve immediate upper denture (D5130), immediate lower 
denture (D5140), a therapeutic parenteral drug, single administration (D9610), a therapeutic parenteral drugs, 
two or more administrations, different medications (D9612), a collection and application of autologous blood 
concentrate product (D7921), alveoloplasty in conjunction with extractions (D7310), adjust complete upper 
denture (D5410), adjust complete lower denture (D5411), a radiographic/surgical implant index (D6190), a 
surgical placement of implant body (D6010) and intravenous moderate sedation D9243). 
 
You asked the Plan to pre-approve dental services. You say that the dental care should be covered under your 
medical benefits because you have a severe infection. You are asking the plan to review and reconsider 
coverage. The Plan denied your request. The Plan says the requested services are not covered by 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 
immediate upper denture (D5130), immediate lower denture (D5140), a therapeutic parenteral drug, single 
administration (D9610), a therapeutic parenteral drugs, two or more administrations, different medications 
(D9612), a collection and application of autologous blood concentrate product (D7921), alveoloplasty in 
conjunction with extractions (D7310), adjust complete upper denture (D5410), adjust complete lower denture 
(D5411), a radiographic/surgical implant index (D6190), a surgical placement of implant body (D6010) and 
intravenous moderate sedation D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling and root planing (D4341 x 2) provided on January 
31, 2022. 
 
You asked the Plan to pay for the dental services. You say that your previous plan covered deep cleaning. You 
say that you feel that you were misinformed about the procedure and benefits. You also say that if your dental 
office had requested an estimate, you would not have done this procedure. The Plan denied your request. The 
Plan says that the claim denied correctly. 
 
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 scaling and root planing are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling 
and root planing (D4341 x 2) provided on January 31, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. Additionally, your functional status was unchanged after 3 months of therapy (twice a week) 
limited by fatigue and low-calorie intake. While you may benefit from physical therapy, and occupational 
therapy, your rehab can be safely provided at a lower intensity and alternate setting such as in a skilled nursing 
facility. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from April 25, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
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 pre-approve continuation of SNF care from April 25, 2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bevacizumab (J9035). 
 
You asked the Plan to pre-approve bevacizumab. You say that the requested medication is medically necessary. 
The Plan denied your request. The Plan says the requested drug is not approved by the FDA for the enrollee's 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 requested drug, bevacizumab, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the reviewer found that the elements of the coverage criteria are not 
satisfied. 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve bevacizumab (J9035).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the K3-level prosthetic knee and ankle/foot system 
described by codes L5981, L5986, L5988, L5814, L5845, L5850, L5925, L5964, and L5999. 
 
You asked the Plan to pre-approve the requested prosthetic components. You say that this is required for the 
enrollee's rehabilitation. The Plan denied your request. The Plan says the requested items are not covered as the 
enrollee is not a K3 ambulator. Also, there is no information showing exposure to extreme environmental 
conditions, and the code L5999 is being used to describe a socket which is incorrect coding. 
 
The Plan follows Medicare rules. Medicare rules say that certain prosthetic components are only covered when 
the enrollee is at a specific functional level. In addition, protective outer coverings are only covered for 
enrollees who have special needs for protection against unusually harsh environmental situations. Lastly, code 
L5999 is not to be used for additional features of a prosthetic socket. 
 
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 requested prosthetic components. 
Our reviewer says that the documentation does not support that the requested components are reasonable and 
necessary. Our physician reviewer found the enrollee is a female with a prior below-the-knee amputation who 
is requesting an advanced lower extremity prosthesis for a K3 ambulator. The documentation indicates that the 
member has diabetes mellitus, hypertension, and chronic osteomyelitis of the right foot who had a below the 
knee amputation of the left lower extremity on 12/31/21. In this case, the documentation does not indicate the 
member is able to ambulate at a K3 level and requires the advanced foot/ankle and knee system. 
 
We looked at this physician's review, the file, and Medicare rules. There is no description of exposure to 
unusually harsh environmental conditions to support coverage for code L5964. L5999 is being used to describe 
a feature of the socket which is not allowed. Based on this information, we decided that Medicare rules for 
coverage of the requested prosthetic components have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the K3-level prosthetic knee and ankle/foot system described by codes L5981, L5986, 
L5988, L5814, L5845, L5850, L5925, L5964, and L5999.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pre-approve Integrated Procedure Unit (IPU) care at an out of network 
palliative care hospital. 
 
You asked the Plan to pre-approve IPU care an out of network facility. You say that there are no in network 
providers available to provide hospice services and continue a full code status. The Plan denied your request. 
The Plan says that the requested services at the out of network facility 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 IPU care an out of network facility. Our 
reviewer says that the requested IPU care at an out of network facility is considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation supports that the type of 
interdisciplinary palliative acute care provided by the requested out of network hospital is reasonable and 
necessary and more appropriate than the care being provided by the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IPU care an out of network facility have been met. Therefore, we decided that 
the Plan has to pre-approve Integrated Procedure Unit (IPU) care at an out of network palliative care hospital.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested scan. You say that the scan will be done past the 12-month 
requirement. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 We looked at the file and the Medicare rules. The rules say that the enrollee must be absent of signs/symptoms 
of lung cancer. The records show that the enrollee has a history of colon cancer with lung metastasis. Based on 
this information, we decided that the Medicare rules for coverage have not been met.  Therefore, we decided 
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer 
screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve SNF care to be provided by an OON provider. You say that the services are 
necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide 
these services. Therefore, coverage criteria have not been met. 
 
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 skilled nursing facility (SNF) care to be 
provided by an out-of-network (OON) provider.
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 based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 are medically stable and does not need physical medicine and rehabilitation 
(PM&R) physician close supervision three (3) times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing needs identified or 
documented in the record. You are not able to participate in and benefit from an intensive regimen of three (3) 
hours per day of physical therapy (PT) and occupational therapy (OT). Hence, you do not need IRF level of therapies, and your rehabilitation needs can be met in a skilled nursing facility (SN)F. IRF admission is not 
medically necessary based on medical stability and lack of rehabilitation nursing needs in addition to inability 
to tolerate therapies. Document does not support the necessity for admission to an IRF. While you may benefit 
from physical therapy (PT), and occupational therapy (OT), your rehabilitation can be safely provided at a 
lower intensity and alternate setting such as in an SNF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest without contrast (CPT 71250). 
 
You asked the Plan to pre-approve a CT scan of the chest without contrast. The Plan denied your request. The 
Plan says your records do not show the size of your nodule. Imaging is not supported without results of prior 
chest imaging for comparison. This is done to see if something that was found on prior imaging is now stable, 
worse, or gone. Your records do not describe these results. 
 
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 CT scan of the chest without contrast. 
Our reviewer says that a CT scan is not medically necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has undergone a chest x-ray that shows apical scarring in 2021. A CT scan of 
the chest at the time did not reveal any parenchymal findings. The provided records do not indicate the medical 
necessity or reasonableness, as defined by Medicare rules, of the requested service.  The elements of the 
coverage criteria are not satisfied.  The requested service cannot be recommended. 
 
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 CT scan of the chest without contrast. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CT scan of the chest without contrast (CPT 71250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental crowns (D2740) provided by a participating provider 
on October 5, 2021. 
 
You asked the Plan to pay for dental crowns. You say that you thought that this would be covered. The Plan 
denied your request. The Plan says the rendered dental services were not covered 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 pay for dental 
crowns (D2740) provided by a participating provider on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on November 21, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (70450) provided on November 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray rendered on December 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the knee x-ray rendered on December 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy on December 10, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you did not realize the copayment is $35 for each visit. You say that you thought the copayment was $10 for each visit and you had to quit physical therapy because you can't afford it. The Plan denied your request. The Plan says copayment 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 $35 copayment for in-network, Medicare covered therapy visits.
You have been asked to pay $35 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation services" 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 the physical therapy on December 10, 2021.