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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with a computed 
tomography (CT) scan skull through mid-thigh. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the records do not show that the enrollee has symptoms of lung cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET/CT scan. Our reviewer says 
that the PET/CT scan is not medically necessary. Our physician reviewer found a low-dose CT scan of the 
chest for lung cancer screening on November 1, 2022, showed no significant nodules. A chest CT angiogram 
showed a borderline enlarged right hilar lymph node of 1.4 centimeter. The enrollee was felt to have 
pneumonia at the time of the hospitalization. A borderline enlarged hilar lymph node would not be unusual in 
an enrollee with an active chest infection. The suspicion for lung cancer, based on the lymph node finding, is 
low, and repeat chest CT imaging in 3 to 6 months would be reasonable. 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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) with a computed tomography (CT) scan skull 
through mid-thigh.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic testing rendered on November 26, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that experimental and investigational services are not covered. 
 
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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that neuromonitoring has become common during many surgical procedures, and it has generally 
replaced intraoperative wake-up testing during spine surgery. Neuromonitoring is performed by a specialized 
team with specific expertise in the techniques that are used. In most instances, no "standard of care" exists for 
intraoperative neuromonitoring, and techniques are chosen by the surgeon and monitoring team in order to 
assess or protect structures at risk. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
diagnostic testing rendered on November 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Precision Neo blood glucose test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you need the test strips in order to 
test your blood. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Precision Neo blood glucose test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be rendered by an out-of-network 
(OON) dental provider.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental 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. 
 
 
  
 
 
 
You are requesting a dental service from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested service is not covered under this benefit when received from an 
out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an office visit to be 
rendered by an out-of-network (OON) dental provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on December 16, 
2022. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like a reconsideration 
of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services provided on December 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve the physical therapy visits. You say that without continued physical therapy 
it is likely that the enrollee will lose their ability to transfer independently in their group home. The Plan denied 
your request. The Plan says 12 additional physical therapy visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with 
outpatient therapies and should be independent with a home exercise program. The enrollee has no recent 
injury or a decline in function. The additional therapy services are not appropriate duration and frequency for 
treatment of the enrollees medical condition and therefore are 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 the physical therapy visits. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crowns (D2799 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford to pay for these 
procedures yourself. The Plan denied your request. The Plan says this procedure is included and paid under the 
crown restoration procedure that has already been approved under authorization A0230420000094. 
 
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 
interim crowns (D2799 x 4).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the scan is necessary to rule out every possible 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is noted to have a memory 
impairment. However, the records did not otherwise support that the member met diagnostic criteria for either 
AD or FTD, let alone both. In such a setting the requested service would not meet the baseline requirement for 
coverage as defined by the NCD. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 enrollee requires the level of intensive 
rehabilitation services provided at an IRF. The Plan denied your request. The Plan says the IRF services 
requested does not meet the requirements for approval. 
 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the knee replacement surgery provided on 
February 14, 2023, and the occupational therapy evaluation provided on February 15, 2023. 
 
You asked the Plan to waive the copayments for the surgery and the occupational therapy evaluation. You say 
that you received inpatient hospital services. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 

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 $100 
copayment for surgery services provided at an outpatient hospital. Your contract with the Plan also clearly says 
that you must pay a $100 copayment for each outpatient hospital facility visit. 
 
The record shows you had an outpatient status. You have been asked to pay a $100 copayment for the surgery. 
You have also been asked to pay $84.28, which is less than the standard copayment for the occupational 
therapy evaluation. These items/services fall within the outpatient surgery, including services provided at 
hospital outpatient facilities 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 the knee 
replacement surgery provided on February 14, 2023, and the occupational therapy evaluation provided on 
February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on March 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 pay for an 
extraction (D7210) provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve foot care/toenail trimming. 
 
You asked the Plan to pre-approve the services. You say that you would like your foot care to be done by a 
podiatrist only. The Plan denied your request. The Plan says that the enrollee should follow up with podiatry 
for a current diabetic foot assessment to determine the next steps in care. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit unless 
you have diabetic foot disease or some other condition that makes professional care of your feet medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Part C Plan was correct in denying the request to pre-approve the services. Our reviewer says 
that the requested services are medically reasonable or necessary. Our physician reviewer found that both 
progress notes demonstrate a diagnosis of onychomycosis, which is a covered service if it is painful. 
Furthermore, the medical documentation supports that you are a diabetic who is being treated with glipizide. 
The physical examination noted in the medical chart reveals non-palpable posterior tibial pulses. A diagnosis of 
diabetic neuropathy is noted in your past medical history/problem list. The medical documentation supports 
that the enrollee does have a covered condition that would necessitate routine foot 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 services have been met. Therefore, we decided that the Plan has to pre-
approve foot care/toenail trimming.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for Home visit for the evaluation and management provided on 
January 19, 2023, to January 27, 2023. 
 
You asked the Plan to pay for Home visit for the evaluation and management. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Home visit for the 
evaluation and management provided on January 19, 2023, to January 27, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the therapy services. You say that there are no network providers that can 
render necessary treatment. The Plan denied your request. The Plan says network providers are available to 
render necessary care. 
 
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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
10, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $370 
copayment for outpatient surgery/other outpatient procedures and services. 
 
You have been asked to pay a $370 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/other outpatient procedures and 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 outpatient surgery provided on March 10, 2023.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says that that the step 
therapy requirements have not been met.  
 
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 Ilumya. Our reviewer says that Ilumya 
is medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drugs Skrizi, Cosentyx, Xeljanz, or Enbreal. There is also no indication that the Plan's required drugs 
would likely be less effective or likely have adverse effects for the enrollee. However, under Medicare rules 
step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollee's that are 
not actively receiving the affected medication. The records indicate the enrollee has been receiving Ilumya and 
has been tolerating and benefiting from it. Therefore, the step therapy rules do not apply. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have been met. Therefore, we decided that the Plan has to pre-approve 
Ilumya.  
 
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.