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

 
We decided that the Plan does not have to pre-approve amifostine. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has stage IV ovarian 
cancer. Amifostine is not Food and Drug Administration (FDA)-approved for the treatment of ovarian cancer 
with carboplatin, paclitaxel, and bevacizumab. The enrollee does not have xerostomia or radiation proctitis. 
The indication for this drug is not clear. The service is 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 amifostine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5298 x 2) 
 
You asked the Plan to pre-approve the hearing aids (V5298 x 2). You say that you are deaf, and you need new 
hearing aids. The Plan denied your request. The Plan says the Plan has not received complete medical records 
from your doctor. We also do not have any signed written order from your doctor and your hearing test results. 
You do not meet the rules for the request. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. Medicare rules say that to consider coverage and payment for any item or service, 
the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's 
medical documentation and confirm that Medicare coverage criteria have been met We looked at the file and the Medicare rules. The file shows that your doctor did not submit sufficient medical documents to justify payment for the requested hearing aids. Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5298 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chemodenervation procedures provided 
from April 7, 2021, to October 6, 2021. 
 
You asked the Plan to waive the copayments for chemodenervation procedures. You say that you receive 
injections in your foot every three months. You also that they take less than ten minutes and do not require any 
special room, equipment, or observation. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $260 
copayment for each outpatient surgery at an outpatient hospital. 
 
 The records show the injections you had are considered surgical procedures. You received the injection on 
April 7, 2021, July 7, 2021, and October 6, 2021. You have been asked to pay a total of $780, which is a $260 
copayment for each chemodenervation procedure ($260 copayment x 3 procedures = $780). Chemodenervation 
procedures falls within the Outpatient Surgery, Including Services Provided 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 
chemodenervation procedures provided from April 7, 2021, to October 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transplant related lodging and transportation, per diem 
provided from December 27, 2020, through October 5, 2021. 
 
You asked the Plan to pay for transplant related lodging and transportation, per diem. The Plan denied your 
request. The Plan says after review, it was determined that date of service December 27, 2020 denied as 
services received prior to evaluation start date and date of service February 7, 2021 denied, as this was a non-
covered.  
 
The Plan contract says if the Plan provides transplant services at a location outside the pattern of care for 
transplants in your community and you choose to obtain transplants at this distant location, we will arrange or 
pay for appropriate lodging and transportation costs for you and a companion.  
We looked at the file and the Plans rules. Based on this information, we decided that the Plans rules for 
coverage of transplant related transportation, per diem have not been met. Therefore, we decided that the Plan 
does not have to pay for transplant related transportation, per diem provided on December 27, 2020, and 
February 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J439). 
 
You asked the Plan to pre-approve Injectafer. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Infed (iron dextran) 
and Venofer (iron sucrose). 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Specifically, the file does not show that the 
enrollee has tried and failed the preferred drugs. Therefore, we decided that the Plan does not have to pre-
approve Injectafer (J439).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 9, 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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shingles vaccine provided on October 1, 2021, under 
Medicare Part B. 
 
You asked the Plan to pay for this vaccine under Medicare Part B. You say that this vaccine should be covered 
by the Plan. The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under 
Medicare Part B. The Plan follows the same rules. The shingles vaccine is preventative and is not covered 
under Medicare Part B. Therefore, we decided that the Plan does not have to pay for a shingles vaccine 
provided on October 1, 2021. Benefits for this vaccine may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 4, 2021, to 
January 27, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim to be 
reprocessed and payment remitted for the services that were rendered. The Plan denied your request. The Plan 
says the RAP was received on April 22, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, January 4, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from January 4, 2021, to January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3330) provided on September 27, 2021, and 
the core buildup (D2950) provided on October 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary, and you were 
unable to obtain prior authorization as you were in too much pain. The Plan denied your request. The Plan says 
the provider in this case is not contracted with the Plan. If you receive care from an out-of-network dental 
provider, you must pay for your own care. 
 
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. Services are only available when provided by contracted in-network dentists. If you receive care from an out-of-network dental provider, you must pay for your own care. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-
network providers are not covered under this benefit. Documentation shows that the provider in this case is not 
part of the Plan's network, and there were in-network providers available to provide this care. Therefore, we 
decided that the Plan does not have to pay for the root canal (D3330) provided on September 27, 2021, and the 
core buildup (D2950) provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) imaging of the 
skull base to mid-thigh (78812). 
 
You asked the Plan to pre-approve PET imaging services. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says PET imaging is not covered by Medicare for 
the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover PET scan services for 
the initial anti-tumor treatment strategy for enrollees who have adenocarcinoma of the prostate.  
 
We looked at the file and Medicare rules. In this case, the requested imaging service is initial anti-tumor 
treatment strategy for an enrollee diagnosed with prostate cancer. Based on this information, we decided that 
Medicare rules for coverage of PET imaging services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve positron emission tomography (PET) imaging of the skull base to mid-thigh 
(78812).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 1, 2021. 
 
You asked the Plan to pay for the dental service. You say that you went to a different dentist to get a second 
opinion. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan 
years. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the 
frequency limit of once every 3 plan years has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on February 2, 2021. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 7, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 7, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
7, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of March 7, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond March 7, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 7, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 7, 
2022, forward.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on March 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
billed with the incorrect place of service. 
 
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 Plan argues that the services should have been billed with POS code 11, as 
the specimen was collected in an office setting. The services in question were billed with POS 11. The Plan has 
not provided documentation supporting its denial. Therefore, we decided that the Plan has to pay for the drug 
testing services provided on March 26, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspiration (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspiration. You say that the service is necessary. The Plan 
denied your request. The Plan says neither Medicare nor the enrollee's Medicare Advantage health plan covers 
the requested service. The Plan states they do not cover the use of bone marrow aspirate for this procedure and 
medical studies have not proven that this procedure is helpful for treatment of the enrollee's health problem. 
 
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 bone marrow aspiration. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested bone marrow aspirate, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone marrow aspiration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspiration (CPT code 20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
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 supplies are available from the preferred provider.  
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file and Medicare rules. The requested test strips are not from the Plan's preferred provider. 
The services are available from the preferred provider. Therefore, we decided that the Plan does not have to 
pre-approve Freestyle Lite test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, below knee, alignable 
system (L5910). 
You asked the Plan to pre-approve the alignable system. You say that you request review of the clinical file 
submission. The Plan denied your request. The Plan says the medical necessity for the alignable system is not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the alignable system. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requirements are not met as the prosthesis is non-alignable and the requested 
addition is alignable. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, medical records provided meet the 
requirements listed in the LCD for Medicare Coverage. 
 
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 alignable system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the addition, endoskeletal system, below knee, alignable system (L5910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the denture. You say that you would like special consideration for this 
denture, as the enrollee lost their previous denture and is unable to eat and speak properly until it is replaced. 
The Plan denied your request. The Plan says the enrollee previously received a complete lower denture in 
January 2020. Complete dentures may only be covered once every five plan years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan can cover one 
complete lower denture (D5120) every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency 
that is not covered under this benefit. Documentation shows that the Plan paid for a complete lower denture for 
this enrollee less than five years before this request. Therefore, we decided that the Plan does not have to pre-
approve a complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 8, 2021, to March 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $325 
copayment per day for days 1-7 of Inpatient hospital care.  
 
 
.. 
 
 
 You have been asked to pay a $1,950 copayment for six days of inpatient hospital care ($325 x 6 = $1,950). 
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 inpatient hospital stay provided from March 8, 2021, to 
March 14, 2021.