Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99349) provided on March 23, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 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 home health services (99349) provided on March 
23, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on March 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that when the 
ambulance arrived, they informed you that you did not need to go to the hospital. You also say that to save your 
money you drove yourself since the ambulance company advised you would be charged a lot more to be 
transported. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 March 30, 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 the ambulance response and treatment with no 
transport provided on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you do not feel like you can prick your finer in order 
to test your sugar levels. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the documentation provided by your physician indicates 
that you do not use insulin or have a history of problematic hypoglycemia. Based on this information, we 
decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) billed for date 
of service June 22, 2022. You asked the Plan to pay for the billed services. You say that the documentation supports the charges.  The 
Plan denied your request. The Plan says there is no detailed history to show why the study was 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 pay for the billed services. Our physician reviewer 
found that the history and indication for the MRA of the brain as dictated by the radiologist was essential 
hypertension. This is not a valid indication for the MRA study that was completed. Therefore, the testing was 
not medically necessary in this case. 
 
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 billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the magnetic resonance angiography (MRA) billed for date of service June 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the requested use is 
not reasonable and 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 physician reviewer 
found that the enrollee has metastatic non-small cell lung cancer. The requested use of Keytruda is not FDA 
approved for the enrollee's diagnosis as Programmed Cell Death Ligand 1 (PD-L1) testing is needed.  
 The requested use is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. The documentation does not support that the requested drug is safe and 
effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that these compression stockings are 
medically necessary. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that due to the enrollee having lymphedema they are not 
safe being at home alone because they are unable to take care of themselves. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary, and the enrollee's needs can be met in another setting.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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, (D6010) for teeth 
#'s 3, 5, 6, and 13, Bone graft (D6104), Implant supported retainer for ceramic (D6075) for teeth #'s 3 and 5, 
implant supported porcelain/ceramic crown (D6065) for teeth #'s 6 and 13, and extraction (D7140) for tooth 
#13, pontic, porcelain/ceramic (D6245) for tooth #4, Interim partial denture, maxillary (D5820) and Interim 
partial denture, mandibular (D5821). 
 
You asked the Plan to pre-approve these dental services . You say that this is medically necessary. The Plan 
denied your request. The Plan says  to be approved the area of this tooth must have an existing tooth in the 
mouth above or below it. Based on the radiographs provided, it appears that an implant at site #'s 3 and 13 
would do not oppose fixed dentition and therefore, would not increase your functionality. The coverage cannot be provided for the surgery to place a metal post in jaw for teeth #'s 5 and 6, tooth-shaped cap (Crown) for teeth 
#'s 6 and 13, tooth-shaped caps (bridge) for teeth #'s 3 and 5, and bone material added for teeth #'s 5 and 13. 
The Staff dentist noted that tooth #14 is missing. The current plan to restore the maxillary dentition with 
extensive implant services does not address this space or the current and future edentulous spaces at sites #'s 3 
and 13. 
 
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 these dental 
services 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 these dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found bone grafts are not a covered service 
under the Plan.  Interim partial dentures are not a covered service under the Plan.  Given the lack of posterior 
support (two points of contact) as required under the criteria (eight points of contact), the implant restorations 
requested would not be considered a covered service.  
 
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 these dental services  have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Surgical placement of implant body, (D6010) for teeth #'s 3, 5, 6, and 13, Bone 
graft (D6104), Implant supported retainer for ceramic (D6075) for teeth #'s 3 and 5, implant supported 
porcelain/ceramic crown (D6065) for teeth #'s 6 and 13, and extraction (D7140) for tooth #13, pontic, 
porcelain/ceramic (D6245) for tooth #4, Interim partial denture, maxillary (D5820) and Interim partial denture, 
mandibular (D5821).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelet rich plasma injection provided on January 26, 2023. 
 
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says a platelet rich plasma 
injection is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered. 
 
We looked at the file and Medicare rules. The record shows the injection was requested to treat a joint 
condition. Based on this information, we decided that Medicare rules for coverage of the injection have not 
been met. Therefore, we decided that the Plan does not have to pay for platelet rich plasma injection provided 
on January 26, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance mileage (A0425) provided on May 16, 2021. 
 
You asked the Plan to pay for the ambulance mileage. You say that this is not a duplicate charge and we are 
asking for a reconsideration. The Plan denied your request. The Plan says that this is a duplicate claim that has 
already been considered. 
 
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 hasnt shown their denial reason is correct as they have not 
submitted proof that the ambulance mileage request is a duplicate charge. Therefore, we decided that the Plan 
has to pay for ambulance mileage (A0425) provided on May 16, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have the extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210). 
 
You asked the Plan to pre-approve the retainer crown and extraction. You say that your benefits indicate that 
crowns are a covered service. The Plan denied your request. The Plan says the retainer crown - 
porcelain/ceramic is not a covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210).
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. You say that the enrollee is medically stable and will 
benefit from a transfer to a specific LTACH. 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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical first film (D0220) provided on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 2, 2022. Therefore, we decided that the Plan does not have to pay for periapical first film (D0220) provided on March 7, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service November 
21, 2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87634 is bundled into 
payment for code 87798. 
 
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 87634 
is a column II code to column I code 87798. This claim has not been billed with an appropriate modifier to 
bypass the edit as modifier 59 is not supported. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87634 billed for 
date of service November 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full body magnetic resonance imaging (MRI) scan. 
 
You asked the Plan to pre-approve the MRI scan. You say that your workman's comp case is almost over, and 
you are requesting to get a full body MRI to make sure everything is okay. The Plan denied your request. The 
Plan says the services are not medically necessary.  
 
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 scan. Our reviewer says that 
the MRI is not medically necessary. Our physician reviewer found there are no orders for a total body MRI nor 
are there orders from a physician for specific MRI exams. This request appears to be your request and has not 
been shown to be medically necessary per submitted material. 
 
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 scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a full body magnetic resonance imaging (MRI) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body, endosteal (D6010), 
semi-precision abutment, placement (D6191) and semi-precision attachment, placement (D6192) for teeth #s 
4, 12, 19, and 29, implant/abutment supported removable denture, partial, maxillary (D6112) and 
implant/abutment supported removable denture, partial, mandibular (D6113). 
 
You asked the Plan to pre-approve these dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says for this service to be approved, you must not be missing multiple teeth on 
both sides of the jaw. Your records that were sent in show that there are multiple teeth missing on both sides of 
your jaw. Placing multiple implants may not be the ideal restorative treatment for your condition.  
 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 these dental 
services 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 these dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the plan does not allow for implant 
restorations where there are multiple missing teeth on both sides of an arch.  In this case #2,3,4,12,13,14,15 (1 
and 16 are impacted) are missing on the upper arch, and #s 18,19, 29,30,31 and 32 are missing on the lower 
arch.  As there are bilateral areas of missing teeth in each arch, the plan criteria have not been met. It is also 
noted that there may be inadequate bone to support an implant at the #29 site without bone 
augmentation.  Under the Plan provisions the requested treatment cannot be authorized. 
 
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 these dental services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical placement of implant body, endosteal (D6010), semi-precision abutment, 
placement (D6191) and semi-precision attachment, placement (D6192) for teeth #s 4, 12, 19, and 29, 
implant/abutment supported removable denture, partial, maxillary (D6112) and implant/abutment supported 
removable denture, partial, mandibular (D6113).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Drug, Breyanzi (Q2054). 
 
You asked the Plan to pre-approve Drug, Breyanzi (Q2054). The Plan denied your request. The Plan says that 
the requested drug, Breyanzi does not meet medical necessity. 
 
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 Drug, Breyanzi (Q2054). Our reviewer 
says that you need this medical item. Our physician reviewer found the documentation supports the requested 
drug, is safe and effective and otherwise reasonable and necessary for this 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 Drug, Breyanzi (Q2054) have been met. Therefore, we decided that the Plan has 
to pre-approve Drug, Breyanzi (Q2054).  
 
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.