Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient level of care for chemotherapy administration. 
 
You asked the Plan to pre-approve inpatient level of care for chemotherapy administration. You say that this is 
medically necessary. The Plan denied your request. The Plan says that this is not medically necessary. 
 
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 inpatient level of care for chemotherapy 
administration. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found this enrollee with extensive central nervous system (CNS) 
involvement of diffuse large B-cell lymphoma will receive both high-dose and intrathecal methotrexate. High-
dose methotrexate is the cornerstone of treatment for primary and secondary CNS lymphoma. Due to the multi-
day dosing of high-dose methotrexate and the need to monitor levels and other labs the treatment is given 
inpatient. 
 
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 level of care for chemotherapy administration have been met. 
Therefore, we decided that the Plan has to pre-approve inpatient level of care for chemotherapy administration.  
 
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 pay for Gradient compression stockings (A6530) provided on March 
9, 2023. 
 
You asked the Plan to pay for Gradient compression stockings. You say that you do not understand why the 
request was denied. The Plan denied your request. The Plan says this request exceeds the frequency limitations. 
 
The Plan must follow Medicare rules. The contract says that the Plan covers Gradient compression stockings 
but is limited up two pairs every six months or surgical stocking up to two pairs every six months.    
 
We looked at the file, Medicare rules and the Plans rules. You previously received covered compression 
stockings on date of service October 25, 2022. You received compression stockings again on March 9, 2023, 
which is less than six months. Therefore, this benefit was exhausted. Based on this information, we decided 
that the Plans rules for coverage of Gradient compression stockings have not been met. Therefore, we decided 
that the Plan does not have to pay for Gradient compression stockings (A6530) provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental cleaning (D1110) and the periodic oral evaluation (D0120) 
provided on March 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says that the services are not payable as they 
have been billed incorrectly by the provider.  
 
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. Specifically, the Plan has stated that the services in this case have been billed 
incorrectly by the provider. However, the Plan has not provided evidence of a billing error. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay 
for the dental cleaning (D1110) and the periodic oral evaluation (D0120) provided on March 9, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  panoramic x-ray of jaws (70355), x-ray of head for 
orthodontia (70350), x-ray exam of body section (76100) and occlusal orthotic appliance (D7880). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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  
panoramic x-ray of jaws (70355), x-ray of head for orthodontia (70350), x-ray exam of body section (76100) 
and occlusal orthotic appliance (D7880).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve diabetic shoes (A5500) and inserts (A5512). 
 
You asked the Plan to pre-approve the items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that your request in this case does not meet Medicare 
criteria for coverage.  
 
Medicare rules state that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all 
of the indicated criteria are met. The Plan follows these same rules.   
 
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 items. Our reviewer says that the 
requested items are medically necessary. Our physician reviewer found that although the medical  
documentation provided is not detailed; it does support that this enrollee suffers with diabetes. There is one 
form enclosed in the medical documentation that advises that this enrollee is diabetic, and suffers with 
peripheral neuropathy with evidence of callous formation. This document is signed by the enrollees physician.  
  
 
This request meets the criteria for coverage of diabetic shoes and diabetic insoles. Therefore, the requested 
diabetic shoes and insoles are medically reasonable and necessary. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have been met. Therefore, we decided that the Plan has to pre-
approve diabetic shoes (A5500) and inserts (A5512). 
 
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: 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 you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the IRF services requested do 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 complexity of the enrollee's medical and therapy needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation 
needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 surgical placement of implant body: endosteal implant 
(D6010), abutment supported porcelain fused to metal crown (high noble metal) (D6059), and custom 
fabricated abutment  includes placement (D6057). 
 
You asked the Plan to pre-approve the dental services represented by codes D6010, D6059 and D6057. You 
say that you do not understand why the authorization was denied when these services are medically necessary. 
The Plan denied your request. The Plan says these services are not listed under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of implant body: endosteal implant (D6010), abutment supported porcelain fused to metal crown 
(high noble metal) (D6059), and custom fabricated abutment  includes placement (D6057).
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 you are requesting an expedited appeal for the denial 
of acute rehabilitation services. The Plan denied your request. The Plan says criteria for admission to the acute 
IRF setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's medical and therapy needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation 
needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 a panoramic radiographic image (D0330). 
 
You asked the Plan to pre-approve the panoramic radiographic image. You say that you want to appeal the 
denial of the x-rays because you need them in order to get your dentures. You also say that you have been 
waiting for 5 months for your dentures. The Plan denied your request. The Plan says your benefit for the 
panoramic radiographic image has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for panoramic radiographic image was exhausted on date of service March 24, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a panoramic radiographic image (D0330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the maxillary and mandibular dentures. The Plan denied your request. The 
Plan says your benefit for the maxillary and mandibular dentures has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the maxillary and mandibular dentures was exhausted on date of service June 3, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
complete denture - mandibular (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal/sinus endoscopy (31237) provided on January 20, 
2023. 
 
You asked the Plan to pay for the nasal/sinus endoscopy (31237). You say that the documentation should be 
reviewed, and the claim processed accordingly. The Plan denied your request. The Plan says procedure code 
31237 is not supported by the medical records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 31237 is a column II code to column I codes 31255 and 31256; 
however, 31237 was billed with a modifier.  
 
We asked our coder 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 nasal/sinus endoscopy (31237). Our reviewer says that 
procedure code 31237 is not supported. Our reviewer found the record does not support that a nasal endoscopy 
with biopsy, polypectomy or debridement was performed as a separate procedure from the approved 
procedures reported for this case.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nasal/sinus endoscopy (31237) have not been met. Therefore, we decided 
that the Plan does not have to pay for the nasal/sinus endoscopy (31237) provided on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services from an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 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 pre-approve dental 
services from an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided November 25, 
2022, to November 26, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee did not need to be admitted 
for this foot pain. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the member was found to have fourth and fifth metatarsal fractures. The member 
refused a skilled nursing facility placement and was discharged home on November 26, 2022, with home health 
physical therapy. The review has determined that the record did not show that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided November 25, 2022, to November 26, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revascularization procedure to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the revascularization procedure. You say that you are requesting 
reconsideration of the denied pre-authorization. The Plan denied your request. The Plan says this service was 
not approved. 
 
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 
the revascularization procedure to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denial with 
supporting documentation. 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 the laboratory services 
provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management treatment to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve pain management treatment. You say that the services should be covered. 
The Plan denied your request. The Plan says this is available in-network. 
 
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 
pain management treatment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of a Transcutaneous Electrical Nerve 
Stimulators (TENS) unit (E0730). 
 
You asked the Plan to pre-approve the continuation of a TENS unit. You say that you need this item. The Plan 
denied your request. The Plan says you have exhausted the 30-day rental period. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is covered for acute post-operative pain. 
Coverage is limited to 30 days (one month's rental) from the day of surgery. Payment will be made only as a 
rental. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuation of a TENS unit have not been met. Specifically, you have exhausted the 30-day 
rental period. Therefore, we decided that the Plan does not have to pre-approve the continuation of a 
Transcutaneous Electrical Nerve Stimulators (TENS) unit (E0730).