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

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve routine transportation. You say that you need to go to this appointment to 
make sure you are free of cancer. The Plan denied your request. The Plan says the requested destination is 
beyond 50 miles per one-way trip. 
 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 Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles of driving distance per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. The requested destination is more than 50 
miles of driving distance per one-way trip. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2332), mandibular partial 
denture (D5214), add tooth to existing partial denture (D5650), extractions (D7140 x 9) provided on April 18, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you believed this provider was in-network and 
the Plan has approved payment for their services in the past. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the resin-based composite (D2332), mandibular partial denture (D5214), add tooth to existing partial 
denture (D5650), extractions (D7140 x 9) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skin growth injection provided on 
December 08, 2022. 
 
You asked the Plan to waive the copayment for a skin growth injection. You say that you feel that this service 
should be totally covered as it was medically necessary. 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 $395 
copayment for in-network Medicare-covered surgery or other services provided at an outpatient hospital. 
 
You have been asked to pay a $395 copayment for a skin growth injection. This item/service falls within the in-network Medicare-covered surgery or other services provided at an outpatient hospital 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. However, since the 
allowed amount is less than the standard copayment, you only owe $172.04. Therefore, we decided that the 
Plan does not have to waive the copayment for a skin growth injection provided on December 08, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic sigmoidoscopy provided on 
March 21, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic sigmoidoscopy. You say that you do not think that 
there should be a copayment for this service. 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 $290 
copayment for each in-network Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $290 copayment for a diagnostic sigmoidoscopy. This item/service falls within 
the each in-network Medicare-covered outpatient hospital facility visit 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 a diagnostic sigmoidoscopy provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement, tooth #19 (D6010). 
 
You asked the Plan to pre-approve implant placement. You say that this is medically necessary. The Plan 
denied your request. The Plan says implants are covered only if they are needed to keep eight (8) teeth in 
occlusion. The information sent by your dentist does not show that this tooth is needed for you to have eight 
teeth in occlusion. The implant is not medically necessary. 
 
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 covers implant 
placement when the services are medically necessary and reasonable.  
 
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 implant placement. Our reviewer says that the service is not medically necessary. Our physician reviewer found the x-rays that were included were 
unreadable, there are not clinical notes included from the provider documenting the necessity for the implant. 
Based off of the information provided, we concur with the plan's denial for D6010 for tooth number 19. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of implant placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve implant placement, tooth #19 (D6010).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing room and board provided from December 14, 
2022, to December 31, 2022. 
 You asked the Plan to pay for the skilled nursing room and board. You say that the enrollee's hospice status 
was revoked on December 2, 2022. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing room and board provided from December 14, 
2022, to December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99309) provided on December 22, 
2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says this provider is non-participating and based on specialty and taxonomy is 
not eligible for Medicare. Also, per CMS taxonomy crosswalk, the taxonomy listed on the claim is not eligible 
to participate in Medicare.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the nursing facility care (99309) 
provided on December 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy for 
decompression of neural elements under indirect image guidance. 
 
You asked the Plan to pre-approve the percutaneous laminotomy/laminectomy for decompression of neural 
elements under indirect image guidance. You say that  the service is medically necessary. The Plan denied your 
request. The Plan says the percutaneous laminectomy is not medically necessary. The Plan says the enrollee 
needs to be a part of a specific Medicare clinical trial to have this service. 
 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 percutaneous laminotomy/ 
laminectomy for decompression of neural elements under indirect image guidance. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found percutaneous laminectomy is experimental, and more research is needed. 
 
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 percutaneous laminotomy/laminectomy for decompression of neural 
elements under indirect image guidance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the percutaneous laminotomy/laminectomy for decompression of neural elements under indirect 
image guidance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0671). 
 
You asked the Plan to pre-approve the services. You say that this order requires a medical Network Adequacy 
Provision (GAP) Exception due to lack of a provider in network. The Plan denied your request. The Plan says 
there are no findings of truncal edema. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was no objective documentation of truncal/abdominal edema to meet the criteria for the 
segmental compression pump to be used. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652, E0671).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BCR/ABL and JAK2 genetic testing. 
 
You asked the Plan to pre-approve BCR/ABL and JAK2 tests. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says there is no indication for these tests. 
 
The Plan follows Medicare rules. Medicare rules state that BCR/ABL and JAK2 genetic tests may be covered 
for certain indications. 
 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 BCR/ABL and JAK2 tests. Our 
reviewer says that the enrollee does not meet criteria for this testing. Our physician reviewer found no 
physician notes are provided that detail the decision-making process for the tests ordered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BCR/ABL and JAK2 tests have not been met. Therefore, we decided that the 
Plan does not have to pre-approve BCR/ABL and JAK2 genetic testing.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided on June 9, 2022. 
 
You asked the Plan to pay for the ER services. You say that the services should be covered. The Plan denied 
your request. The Plan says the Plan is not responsible for this payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.  Medicare covers services in an emergency department only if the 
emergency clinic is affiliated with a hospital. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program and is a Freestanding Emergency Department. Therefore, we decided that the Plan does not have to 
pay for the emergency room (ER) services provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services (99442, 99443) provided on August 
25, 2022, to February 8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the telehealth services. You say that the service should be covered. The Plan 
denied your request. The Plan says telehealth services are not covered when obtained out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that virtual care is not covered when obtained out-of-network. 
 
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 the telehealth services (99442, 99443) provided on 
August 25, 2022, to February 8, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 9, 2023, to 
January 11, 2023. 
 
You asked the Plan to pay for the medication. You say that authorization for services was received under auth 
#167096224. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from January 9, 2023, to January 11, 2023.  
 
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on February 13, 2023, 
through February 16, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on February 13, 2023, through February 16, 2023.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria. You also say the 
requested IRF services are necessary to optimize the enrollee's mobility and strength while ensuring the 
restoration of functional status for a safe and sustainable discharge. The Plan denied your request. The Plan 
says the enrollee does not meet Medicare guidelines for admission to an IRF.  
 
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 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, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient 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 an IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on March 29, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that this was part of the services received in 
the emergency room and you feel the charges should be covered. The Plan denied your request. The Plan says 
the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on March 29, 2023.  
 
Benefits for the self-administered drugs 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 You asked the Plan to pre-approve Lucentis. You say that you are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says 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 Lucentis. Our reviewer says that the 
criteria for coverage of Lucentis have not been met. Our physician reviewer found the Plan requires a trial of 
Eyelea before they will approve Lucentis. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services and air mileage 
provided on October 6, 2022. You asked the Plan to pay for the ambulance service, conventional air services and air mileage. You say that 
the enrollee required critical care monitoring during the flight and sedation for anxiety and agitation, which was 
needed to prevent the patient from pulling out the intravenous line. The Plan denied your request. The Plan 
says after reassessing the entire clinical situation, information provided at the time of the appeal does not 
support criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 ambulance service, conventional air 
services and air mileage. Our reviewer says that the air ambulance services were not medically necessary. Our 
physician reviewer found the enrollee presented with altered mental status in the setting of multiple infections 
(urinary tract infection, Clostridium difficile, and COVID-19). The enrollee was hemodynamically stable. It is 
not clear that transfer for neurology services was medically necessary. The documentation does not show that 
all closer facilities were unavailable. As such, the air ambulance transfer is not shown to be medically 
necessary or eligible for 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 ambulance service, conventional air services and air mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, conventional air services 
and air mileage provided on October 6, 2022.