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

 
We decided that the Plan does not have to pre-approve a second opinion referral office visit to be provided by 
an OON provider. 
 
You asked the Plan to pre-approve a second opinion referral office visit. You say that you are asking to see 
doctors outside of the network. You say that the Plan doesn't appear to have enough doctors who can treat 
patients with complex and serious illnesses. The Plan denied your request. The Plan says care for your medical 
condition is available with in-network providers. 
 
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 
a second opinion referral office visit to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three clinical crown lengthenings (D4246 x3). 
 
You asked the Plan to pre-approve the clinical crown lengthenings. You say that you want to fix your denture, 
but cannot afford to pay for the work yourself. The Plan denied your request. The Plan says this service is a 
non-covered benefit under your dental coverage. 
 
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 three 
clinical crown lengthenings (D4246 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on April 22, 2022, to May 12, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visits. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visits provided on April 22, 2022, to May 
12, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 
diagnosis of triple negative breast cancer. The record does not indicate that the requested drug was used as part 
of a neoadjuvant regimen. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a 
supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mobile cardiac outpatient telemetry (MCOT). 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MCOT is covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
palpitations. The guidelines do not support the use of MCOT in this setting. The service are therefore not 
reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve mobile cardiac outpatient telemetry (MCOT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81529) provided on May 2, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say Molecular diagnostic tests used to assist in risk 
stratification of melanoma patients are covered when the test has shown utility beyond clinical, histological, 
and radiographical factors in the ability to accurately stratify patients into risk groups to manage patient 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 pay for the genetic testing. Our reviewer says that 
this service was not medically necessary. Our physician reviewer found the results of this testing would not 
impact clinical decision-making this patient, and the current National Comprehensive Cancer Network 
Guidelines do not support its use. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81529) provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) image capture 
with field of view of both jaws (D0383). 
 
You asked the Plan to pre-approve a cone beam CT image capture. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's benefit 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 a 
cone beam computed tomography (CT) image capture with field of view of both jaws (D0383).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that you need the wheelchair to get more 
control and be more comfortable. The Plan denied your request. The Plan says the coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications. 
 
The file shows that a group 2 heavy duty power wheelchair, with a weight capacity of 301-450 pounds has 
been requested. We looked at the file and Medicare rules. The records do not show that your home provides 
adequate access or that you meet the weight requirements for the requested chair. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Spitfire brand power scooter (power operated vehicle). 
 
You asked the Plan to pre-approve Spitfire brand power scooter. You say that you need a lightweight scooter 
due to difficulty lifting heavy items. The Plan denied your request. The Plan says the denial of authorization for 
this device is correct, because Spitfire is not one of the Plan's preferred brands and your needs can be met by a 
preferred-brand power scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may generally limit coverage of DME to 
certain brands.  
 
We looked at the file and Medicare rules. The requested power scooter is not among the Plans preferred 
brands. The record does not show why your needs cannot be met by a power scooter from a brand preferred by the Plan, and the Plan has recommended several preferred-brand products which are actually lighter in weight 
than the power scooter you requested. Based on this information, we decided that Medicare rules for coverage 
of Spitfire brand power scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Spitfire brand power scooter (power operated vehicle).
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 the enrollee was admitted to the hospital for a urinary tract infection and 
cholecystectomy and is now medically stable with no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the portable concentrator is 
medically necessary. The Plan denied your request. The Plan says the enrollee has portable tanks that meet the 
enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have portable oxygen tanks. The portable concentrator serves the same purpose as the 
portable tanks. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen 
concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient diagnostic and outpatient 
surgery on June 19, 2021, to August 24, 2021. 
 
You asked the Plan to waive the copayments for outpatient diagnostic and outpatient surgery. You say that you 
want to appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are 
being charged is correct.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $130 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. You must pay a $370 copayment for Medicare-covered surgery or other services provided to you at an 
outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical 
charges. The provider billed in the amount of $462.90 and the allowed amount is $308.82. This is less than the 
copayment amount. $130 + $308.82 = $438.82. Therefore, results in the total cost sharing amount of $438.82. 
 
You have been asked to pay a $130 copayment for outpatient diagnostic and a $308.82 copayment, which is 
less than the copayment for outpatient surgery. Outpatient diagnostic and outpatient surgery falls within the 
Outpatient diagnostic tests and tests and therapeutic services and supplies and Outpatient surgery and other 
medical services at hospital outpatient facilities and ambulatory surgical centers 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 copayments for outpatient diagnostic and outpatient surgery on June 19, 2021, to 
August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basket for a walker. 
 
You asked the Plan to pre-approve a basket for a walker. You say that this is necessary for when you are 
shopping. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
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 basket for a walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system, includes 
all accessories and supplies, each (HFCWO), (E0483) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the HFCWO. You say that the enrollee needs this device. The Plan denied 
your request. The Plan says the requested service can be provided in network. 
 
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 
a high frequency chest wall oscillation system, includes all accessories and supplies, each (HFCWO), (E0483) 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from intensive 
inpatient rehab with daily physician visits and exams. The Plan denied your request. The Plan says the request 
is not medically necessary and the services you need can be provided safely in other settings. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 therapeutic parenteral drugs (D9610), incisional 
biopsies on tooth #8 and 12 (D7286), excision of benign lesions on tooth #26 (D7410), and osseous surgery in 
all four quadrants (D4260). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says therapeutic parenteral drugs (D9610), incisional biopsies (D7286), 
excision of benign lesions (D7410), and osseous surgery (D4260) are not covered by the enrollee's 
supplemental dental benefits. 
 
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 
therapeutic parenteral drugs (D9610), incisional biopsies on tooth #8 and 12 (D7286), excision of benign 
lesions on tooth #26 (D7410), and osseous surgery in all four quadrants (D4260).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liposuction or ultrasonically assisted liposuction 
(suction assisted lipectomy; trunk) (15877) and excision, benign lesion including margins, except skin tag 
(unless listed elsewhere), trunk, arms or legs (11400). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee has pain and discomfort 
due to back mass. Given their symptoms, the enrollee is indicated for surgery, including liposuction and 
possible resection. The Plan denied your request. The Plan says documentation of a functional impairment 
related to the procedure was not submitted. Cosmetic surgery is done to improve your appearance and is not 
covered by your health plan. Liposuction is considered cosmetic and is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
reviewer found in this case, the record indicates that the enrollee has excessive adipose tissue located in the 
posterior neck and upper back. The record provided does not document that the enrollee has a condition for 
which coverage of the requested procedure is available. The records provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve liposuction or ultrasonically assisted liposuction (suction assisted lipectomy; 
trunk) (15877) and excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, 
arms or legs (11400).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an infrared boot. 
 
You asked the Plan to pre-approve the infrared boot. You say that the infrared boot is medically necessary. The 
Plan denied your request. The Plan says this device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that use of infrared and/or near infrared light and/or 
heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such 
as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds 
and/or ulcers of the skin and/or subcutaneous tissues. 
 
We looked at the file and Medicare rules. This equipment is non-covered under Medicare rules for the 
treatment of neuropathy. Based on this information, we decided that Medicare rules for coverage of the infrared 
boot have not been met. Therefore, we decided that the Plan does not have to pre-approve an infrared boot.