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

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is not covered on 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 a 
guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three free soft tissue graft procedures of the first tooth 
(D4277 x3) and three free soft tissue graft procedures of each additional contiguous tooth (D4278 x3). 
 
You asked the Plan to pre-approve the free soft tissue graft procedures. You say that the Plan has denied these 
procedures which will keep your teeth healthy. The Plan denied your request. The Plan says these procedures 
are not included as covered procedures in your Evidence of 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 
free soft tissue graft procedures of the first tooth (D4277 x3) and three free soft tissue graft procedures of each 
additional contiguous tooth (D4278 x3).
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 IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules for IRF care have 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 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 
inpatient rehabilitation 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport provided on 
January 23, 2022. 
 
  You asked the Plan to waive the copayment for an ambulance transport. You say that you are disputing that 
you should be responsible for the copayment plus an additional fee for oxygen supplies. You say that the need 
for an ambulance transport was completely unnecessary if the oxygen had been delivered on time as requested. 
The Plan denied your request. The Plan says $28.55 for the oxygen and oxygen supplies has been waived 
because you cannot be balance billed. The Plan also says the $250 copayment applied correctly to the transport. 
 
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 $250 
copayment for each one-way Medicare-covered ground trip. 
 
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance 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 
an ambulance transport provided on January 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Tecentriq (J9022) and Abraxane (J9264). 
 
You asked the Plan to pre-approve Tecentriq and Abraxane. You say that the requested drug regimen is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules have 
not been met because the requested drug regimen is prescribed for an off-label and not medically accepted use. 
 
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 Tecentriq and Abraxane. Our reviewer 
says that the requested drug regimen is not medically reasonable and necessary in this case. Our physician 
reviewer found that the requested use of Tecentriq and Abraxane is not FDA-approved for the enrollees 
diagnosis. Additionally, the use is not supported by one of the major drug compendia or by clinical research 
that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq and Abraxane have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment with Tecentriq (J9022) and Abraxane (J9264).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan. 
 
You asked the Plan to pre-approve a SPECT scan. You say that you need this test because your doctor referred 
you for it. The Plan denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a SPECT scan is useful in the diagnosis of several 
conditions. 
 
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 SPECT scan. Our reviewer says that a 
SPECT scan is not medically reasonable and necessary. Our physician reviewer found you were due for a 
repeat electrocardiogram (EKG), but had no symptoms currently. Our reviewer also found that the medical 
necessity for a myocardial perfusion scan using SPECT has not been established in the records provided. 
 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitors (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee has limited ability to use 
his left arm, along with intermittent spasticity in the left hand, making it impossible to use a traditional glucose 
monitor at home. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitors (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from LTACH 
care. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be 
appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic 
advantage. 
 
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 that the documentation does not support that the enrollee has a need for complex 
medical treatment in an LTACH. The enrollee does not require services at the LTACH that are not available at 
the acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at 
the LTACH level of care. The enrollee has stabilized medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 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 long term acute care hospital (LTACH) services.
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 IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules for IRF care have 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 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 
inpatient rehabilitation 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical-necessity rules for SNF care have not been 
met. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs or skilled therapy 
needs. The enrollee is functioning at a level commensurate with the enrollee's upper-extremity weight-bearing 
restriction. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Theraskin, per square centimeter (Q4121). 
 
You asked the Plan to pre-approve Theraskin. You say that additional records were submitted, and you are 
requesting reconsideration for the denial. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for approval. 
 
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 Theraskin. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare does not cover skin substitutes to ulcers or wounds unless the area is clean and free of 
necrotic debris or exudate. Clinical evidence of abscess was noted within the medical notes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Theraskin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Theraskin, per square centimeter (Q4121).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on April 7, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this type of 
provider is not eligible to bill these services. 
 
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. The provider in question is an MD with a specialty in histology. First, the Plan 
says that this type of provider is not eligible to bill for assistant surgery service, but the services in question are 
not assistant surgery services. Second, the Plan says that this type of provider is not eligible to enroll in 
Medicare. However, an MD with a specialty in histology is eligible to enroll in Medicare and bill for Medicare 
services. The Plan has not provided documentation supporting its denial. Without supporting documentation, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services 
provided on April 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for injection on April 12, 2022, to April 26, 2022 
 
You asked the Plan to waive the copayments for injection. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $0 copayment for surgical procedures performed by 
physician/practitioner in a provider office. Covered services include medically-necessary medical care or 
surgery services furnished in a physicians office, certified ambulatory surgical center, hospital outpatient 
department, or any other location. 
 
The Plan says you must pay a $244 copayment for each injection. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for injection. Therefore, we decided that the Plan has to 
waive the copayments for injection on April 12, 2022, to April 26, 2022  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ThyGeNEXT testing rendered on August 17, 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 were not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that biomarker testing 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a nontoxic single thyroid 
nodule. Fine needle aspiration on August 17, 2021 was suspicious for malignancy (Bethesda Category V), and 
suspicious for papillary thyroid carcinoma. The records do not support that the nodule has a history or 
characteristics suggesting malignancy. The services were 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 pay for the ThyGeNEXT testing rendered on August 17, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a lap sleeve gastrectomy. 
 
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 bariatric surgery 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 medically necessary. Our physician reviewer found the enrollee has a body mass index (BMI) 
of 40 kg/m2, gastroesophageal reflux disease (GERD), hyperlipidemia, pre-diabetes, and knee pain. She has 
failed efforts at medical weight loss. The requested lap sleeve gastrectomy is reasonable and medically 
necessary for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a lap sleeve gastrectomy.  
 
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.