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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you urgently require an extension of trips 
since your 34 trips to the doctor have been consumed. You also say that you need more trips since the next 
appointment is for October 2, 2023.  The Plan denied your request. The Plan says your benefit does not cover more than 34 one-way trips per plan 
year. Per the plan records, you have utilized 34 one-way non-emergency transportation trips for this benefit 
year of 2023. 
 
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 a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips for your medical appointments. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the services are medically necessary and there is 
evidence of osteoarthritis in the medical records that were provided. The Plan denied your request. The Plan 
says that the enrollee does not meet the criteria for approval based on the records received. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found that the enrollee has a history of right knee 
pain due to unilateral primary osteoarthritis. Zilretta is indicated as an intra-articular injection for the 
management of osteoarthritis pain of the knee. With regards to the enrollee's history of diabetes, both Zilretta 
and other corticosteroid injections have the same warnings for hyperglycemia in their package insert. There is 
no differentiation of one being more beneficial than another in terms of reduced incidence of hyperglycemia. 
The documentation provided supports that Zilretta is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve 
Zilretta.  
 
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 the enrollee is appealing the denial of the requested 
inpatient rehabilitation facility (IRF) services. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a 
lumbar fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do 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 
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 you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the thorax, abdomen, and pelvis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records show the enrollee has been treated for cancer in the anus, and this 
service is only supported once a year for three years after treatment is completed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that this is necessary 
given the new pathology of proven (resected) metastatic disease for surveillance to rule out new recurrence. It 
is also needed for post-therapy (surgical resection) evaluation and assessment. 
 
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 computed tomography (CT) of the thorax, abdomen, and pelvis.  
 
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 pay for a limited oral evaluation (D0140) provided on July 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had to go to an endodontist, and they 
needed to do their own 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 May 3, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 dental services provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 7, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says they have paid the maximum allowed by the enrollees 
Health Plan. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist called and got verbal authorization. 
You say that you should not be punished for this. 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 dental services provided by an out-of-network provider on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services provided on October 
12, 2022, to October 26, 2022. 
 
You asked the Plan to pay for transitional care management services. You say that you were not aware of the 
correct procedure. The Plan denied your request. The Plan says the primary payer will need to review the 
services for payment consideration before the Plan can consider the claim for payment consideration as 
secondary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the insurance 
that pays first is called the "primary payer" and pays up to the limits of its coverage. The one that pays second, 
called the "secondary payer," only pays if there are costs left uncovered by the primary coverage. As the 
secondary insurer, the Plan cannot be held responsible for transitional care management services until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for transitional care management services provided on October 12, 2022, to October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous process spacer device (the Minuteman). 
 
You asked the Plan to pre-approve the Minuteman. You say that the Minuteman is medically necessary. 
The Plan denied your request. The Plan says the requested Minuteman is considered experimental, 
investigational and unproven.  
 
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 Minuteman. Our reviewer says 
that the requested Minuteman is not considered medically reasonable and necessary. Our physician reviewer 
found that the Minuteman device is experimental. 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 Minuteman have not been met. Therefore, we decided that the Plan does 
not have to pre-approve interspinous process spacer device (the Minuteman).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services (D2950) for tooth #2 and a 
porcelain/ceramic crown (D2740) for tooth #1.  
 
You asked the Plan to pre-approve the core buildup services and the crown . You say that the documentation 
provided supports the need for the services in dispute. The Plan denied your request. The Plan says the dental 
x-rays do not show that there is a medical need for the enrollee to have the requested services by themselves. 
The Plan says that the enrollee's teeth are not able to be fixed by the services in dispute because the decay goes 
down to the bone. The Plan says that the enrollee should check with their dentist for other options.  
 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 the core 
buildup services and the crown 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 the core buildup services and the 
crown. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
bitewing x-ray from July 25, 2023, shows severe decay into the nerve area of tooth, and the decay was not at 
level of the bone. The periapical x-ray for tooth number 20 from August 18, 2023, shows extensive decay of 
the tooth, rendering the tooth non-restorable. Only periapical x-rays were included after this date for tooth 
number 20, and therefore cannot adequately determine the level of bone around the tooth, as periapical x-rays 
do not show a true picture of the bone level. From the periapical x-rays reviewed for the tooth, the decay looks 
extensive making the tooth non-restorable with a buildup and a crown. Based off the records provided, D2950 
and D2740 are not medically reasonable or necessary. 
 
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 the core buildup services, and the crown have not been met. Therefore, we 
decided that the Plan does not have to pre-approve core buildup services (D2950) for tooth #2 and a 
porcelain/ceramic crown (D2740) for tooth #1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on May 1, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152 59 (1 Unit ) remains not supported. 
 
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, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older."  
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report describes a 
surveillance colonoscopy with moderate sedation. In this case, there is a more appropriate code to report for 
this. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on May 1, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the records provided support the need for continued 
SNF care.  The Plan denied your request. The Plan says the requirements for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee has had clinical and functional 
status change. Therefore, the enrollee would be expected to require continued assessment by skilled nursing 
and skilled therapy. The clinical documentation shows that the enrollee's prior level of function (PLOF) was 
supervision with mobility and self-care tasks and that their current level of function (CLOF) is supervision with 
mobility (ambulating 150ft) and self-care tasks. The clinical documentation does not specify any daily skilled 
nursing needs thus does not support the medical necessity for continued daily skilled services. From a practical 
standpoint, the clinical documentation does not support the medical necessity for continued daily skilled 
services on an inpatient basis 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trastuzumab and pertuzumab. 
 
You asked the Plan to pre-approve trastuzumab and pertuzumab. You say that the requested drugs are 
medically necessary. The Plan denied your request. The Plan says the combination use of trastuzumab and 
pertuzumab for this enrollees tumor would be considered experimental and investigational. 
 
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 trastuzumab and pertuzumab. Our 
reviewer says that the requested drugs do not meet the necessary criteria for approval. Our physician reviewer 
found these drugs are not medically reasonable or necessary for a few reasons. The enrollee's cancer is not 
human epidermal growth receptor 2 positive (HER2+) overexpressed gastroesophageal GE) junction cancer. 
The cancer is v-erb-b2 avian erythroblastic leukemia viral oncogene homolog 2 (ERBB2) mutated. There is no 
role for Trastuzumab in this type of cancer. Additionally, even if the enrollee's cancer was actually HER2+, 
Pertuzumab would not be approvable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trastuzumab and pertuzumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve trastuzumab and pertuzumab.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories (E0955, E1002, E1012, E1028, E2361, E2607, E2620, K0108, K0856).  

You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
are met. 
 
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 group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter or have spasticity 
impacting positioning. 
 
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 group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option and accessories (E0955, E1002, E1012, E1028, E2361, E2607, E2620, K0108, K0856).