Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The laboratory test at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants (D6010). 
 
You asked the Plan to pre-approve the implants. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve the proton beam radiation therapy.
You asked the Plan to pre-approve the proton beam radiation therapy. You say that you would like reconsideration because the proton beam therapy will significantly reduce radiation exposure to member's brain. The Plan denied your request. The Plan says that the requested proton beam therapy is not the appropriate treatment for the member's condition.
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 the proton beam radiation therapy. Our reviewer says that the member's condition is a covered indication for proton beam therapy. Our physician reviewer found additional research states that the high conformality of proton therapy does not appear to compromise local control and there is no increased early toxicity. Given the results, the lower dose to the hippocampi and temporal lobes should reduce the neurocognitive impact of radiotherapy. 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 proton beam radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve the proton beam radiation therapy.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is needed for dialysis appointments. The Plan denied your request. The Plan says the requested service is covered under the plan, but the requested amount exceeds the limit listed by the plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging positron emission tomography (PET) services.
You asked the Plan to pre-approve the brain imaging PET services. You say that the enrollee needs the requested PET scan in order to support the presence of Alzheimer's disease or frontotemporal dementia. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimer's disease (AD) and Frontotemporal dementia (FTD). 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 brain imaging PET services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there was no indication in the records that the enrollee was ever suspected of having both AD and FTD. 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 brain imaging PET services have not been met. Therefore, we decided that the Plan does not have to pre-approve brain imaging positron emission tomography (PET) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergent ambulance transportation 
services (A0428, A0425) provided on May 23, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the transfer and 
subsequent transportation were not your choice, so you should not be responsible for this cost. The Plan denied 
your request. The Plan says this claim was processed correctly, and your copayment was assessed in 
accordance with your contract. 
 
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 $220 
copayment for Medicare-covered ambulance services.  
 
 
You have been asked to pay a $98.33 copayment for the ambulance transportation. 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 non-emergent ambulance transportation services (A0428, A0425) provided on 
May 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4381, D4921). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D4381, D4921).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 1, 2020. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered on April 27, 
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 DecisionDx-Melanoma 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 melanoma with 
Breslow thickness of 1.9 millimeters and several melanoma in situ lesions. The record shows that, fo r the 
deeper lesion, sentinel node biopsy is being planned with surgical excision. Adjuvant therapy is not being 
planned. For the superficial lesions, the record indicates that the enrollee is not being considered for further 
surgical therapy. The elements of the coverage criteria are not satisfied; therefore, the testing was 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 DecisionDx-Melanoma testing rendered on April 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
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. 
 
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 at the time of admission into the facility the 
enrollee was medically stable. The enrollee did not require any skilled nursing or rehab services on a daily 
basis at an inpatient level of care. The enrollee was not expected to make measurable gains within a reasonable 
and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of 
daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance 
program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF 
level of care at the time of discharge from the hospital. The enrollee did not have any parental medication, daily 
complex wound care or nutrition given via a feeding tube. The enrollee was medically stable without any acute 
exacerbations of chronic medical problems. The enrollee's physical function was at or near their baseline and 
the enrollee could have received further services at a lower level of care. Admission to the nursing facility at a 
skilled level of care for inpatient skilled services was 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic radiation therapy (SRT) for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says this type of therapy is not shown to be a way to treat basal cell carcinoma. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is a lack of demonstration of need for the requested stereotactic radiation therapy versus traditional 
external beam radiation. There are statements from National Comprehensive Cancer Network (NCCN) 
guidelines and medical societies that question the use of SRT. It would therefore not be considered to be 
furnished in accordance with accepted standards 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stereotactic radiation therapy (SRT) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 18, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you had severe pain in your bottom right molar 
region when chewing food. You say that the initial dentist you saw does not extract certain teeth. You say that 
you were referred to this dentist as a result. You also say that you were not aware of the frequency limitation if 
there is an emergency situation. The Plan denied your request. The Plan says 1 limited oral evaluation is 
covered per plan year. The Plan also says that the frequency limit has been exceeded. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The 
record shows that the Plan paid for a limited oral evaluation that you received on March 25, 2021.  
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 28, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that this was a continuation of care evaluation. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and authorization was not obtained.  
 
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 an office visit provided on May 28, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on March 10, 2021.
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 that 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4265 for tooth numbers 23, 24, 25, 26, 
and 27). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D4265 for tooth numbers 23, 24, 25, 26, and 27).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve at the in-network copayment various home health 
services to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve at the in-network copayment various home health services. You say that this 
care is medically necessary. The Plan denied your request. The Plan says in-network providers are available to 
provide the care you need. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you are allowed to get your care form an OON provider. However, care from an OON provider 
may be more expensive than care from an in-network provider. 
 
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 at the in-network copayment these items/services. Therefore, we decided that the Plan 
does not have to pre-approve at the in-network copayment various home health services to be provided by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on June 15, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that your spouse called 911 for medical 
assistance. You say that you were advised your condition was a medical emergency and needed to go to the 
emergency room. You say that you declined transport. You also say that you were not able to review your 
coverage to determine a course of action. The Plan denied your request. The Plan says there was no transport 
provided. The Plan also says that since no transport was provided, there is no coverable service.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 15, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on June 15, 2021.