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

 
We decided that the Plan does not have to pay for a guide tissue regeneration (D4266), and a bone replacement 
graft for ridge preservation (D7953) provided on September 6, 2023. 
 
You asked the Plan to pay for D4266 and D7953. You say that you needed all of this dental work. The Plan 
denied your request. The Plan says the denied dental services are not covered 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 a guide 
tissue regeneration (D4266), and a bone replacement graft for ridge preservation (D7953) provided on 
September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental exam. The Plan denied 
your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted on date of service January 19, 2023, and 
July 24, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) provided on October 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), complete 
series of x-ray images (D0210), resin-based composite (D2392), periodontal scaling and root planning (D4341 
x 2) and extraction (D7140) provided from September 28, 2023, to October 2, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the charges should be covered in full 
because of the enrollee's limitation to travel to an in-network provider due to their breast cancer. The Plan 
denied your request. The Plan says the enrollee is responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider and the criteria for coverage 
of D4341 have not been met. 
 
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 must follow 
Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to 
the intermediary or carrier sufficient information to determine whether payment is due and the amount of 
payment. 
 
We looked at the file and the Plans rules. Based on this information, we decided that there is insufficient 
information in the record to determine if the Plans rules for coverage of periodontal scaling and root planning 
(D4341) have been met. X-rays and periodontal charting were not provided to determine the medical necessity 
of D4341 for the enrollee. 
 
The enrollee have been asked to pay the difference between the out-of-network providers charges and the 
Plans payment. This cost sharing is a contractual obligation the enrollee agreed to pay when they enrolled in 
the Plan. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation 
(D0150), complete series of x-ray images (D0210), resin-based composite (D2392), periodontal scaling and 
root planning (D4341 x 2) and extraction (D7140) provided from September 28, 2023, to October 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging services (MRI). 
 
You asked the Plan to pre-approve the MRI services. You say that the enrollee has left hip pain and some 
arthritis in the hip. Pain is laterally based and directly able to be palpated and has had an injection over the 
greater trope by the enrollee's primary care without resolution of symptoms. An MRI of the hip will evaluate 
any abductor tendon injury. The Plan denied your request. The Plan says the enrollee does not meet the medical 
necessity criteria for the requested MRI of the hip. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found there is no history of trauma, no red 
flag in the medical records and the enrollee has not had physical therapy yet. 
 
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 MRI services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the magnetic resonance imaging services (MRI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance response without transport provided on June 4, 
2023. 
 
You asked the Plan to pay for an ambulance response without transport.. You say that you saved the Plan 
money by declining transportation. The Plan denied your request. The Plan says without transport, ambulance 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 4, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for an ambulance response without transport provided 
on June 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response without transport on September 15, 
2023. 
 
You asked the Plan to pay for ambulance response without transport. You say that you did not receive transport 
services due to your doctor being out-of-network. The Plan denied your request. The Plan says ambulance 
services without transport are never covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 15, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response without transport on 
September 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Auvelity. 
 
You asked the Plan to pre-approve Auvelity. You say that the medication is 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 pre-approve Auvelity.  Benefits for Auvelity 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on August 
22, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that after being evaluated, it 
was determined that you did not need to go to the hospital. The Plan denied your request. The Plan says the 
Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 22, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on August 22, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from July 25, 2023, 
through September 6, 2023. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you contracted COVID-19 and 
could not leave the facility earlier. 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 for days 
1-20: $0 copayment per day and days 21-100: $196 copayment per day. 
  You have been asked to pay a $1,274.62, which is less than the standard $4,312 copayment for the SNF stay. 
This item/service falls within the skilled nursing facility (SNF) care benefit category. From dates of service 
July 25, 2023, to August 13, 2023, is 20 days with $0 copayment. From dates of serviced August 14, 2023, to 
September 6, 2023, is 22 days (22 days x $196 per day = $4,312). This means that you have been asked to pay 
a lesser copayment amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the SNF stay provided from July 25, 2023, through September 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections and procedures. 
 
You asked the Plan to pre-approve sacroiliac joint injections and procedures. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
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 sacroiliac joint injections and 
procedures. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental procedure because of 
the wide variation in efficacy reported in the peer reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injections and procedures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sacroiliac joint injections and procedures.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's wound care requires 
specialized LTACH with advanced knowledge and skills of the wound healing process. The Plan denied your 
request. The Plan says when the enrollee is ready to leave the hospital, they can receive their care in another 
setting such as a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving on current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the request for Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 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 Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the requested use of Keytruda is not 
FDA-approved for the enrollees diagnosis. The use of Keytruda is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The request for Keytruda 
cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service August 30, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the testing is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient records that show the stage of 
cancer or how this testing will influence the treatment of the enrollees condition. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pay for the lab testing billed for date of service August 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart.  
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover the requested study for 
screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a 
screening service. When performed in association with CT angiography, there is neither separate nor additional 
included reimbursement for the calcium scoring. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to pre-
approve a CT scan of the heart.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for the billed code. You say that the code should not be bundled. The Plan denied 
your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 83789 billed for date of service March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is a standard of care. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 a HFCWOD. Our reviewer says that the 
enrollee does not meet criteria for this device. Our physician reviewer found the enrollee has pneumonia and 
likely chronic obstructive pulmonary disease (COPD) exacerbation without data to support prolonged 
bronchiectasis exacerbation. Hence, there is no indication for a HFCWOD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group 1 standard power operated vehicle (K0800) 
purchased on June 8, 2023. 
 
You asked the Plan to pay for the group 1 standard power operated vehicle. You say that you believe the claim 
for reimbursement of a physician recommended purchase of a motorized scooter for a patient with Multiple 
Sclerosis to have some mobility is fully warranted from the Plan and the decision to deny benefits should be 
reversed. The Plan denied your request. The Plan says based on Medicare guidelines, the power operated 
vehicle (K0800) that you are requesting does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the group 1 standard power operated 
vehicle have been met. Specifically, the provided records do not include an evaluation by a physical or 
occupational therapist, a home evaluation, or an SWO. Therefore, we decided that the Plan does not have to 
pay for the group 1 standard power operated vehicle (K0800) purchased on June 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve euflexxa injection. 
 
You asked the Plan to pre-approve euflexxa injection. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
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 euflexxa injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found randomized controlled trials have found that viscosupplementation lacks efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of euflexxa injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve euflexxa injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee only requires short-term acute care at the current facility until they 
are more appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH 
that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.