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

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120),  
prophylaxis - adult (D1110), intraoral - periapical first radiographic image (D0220) and bitewings - four 
radiographic images (D0274) provided on February 18, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that there should be clarification that out-of-network 
even for preventive services is only paid for what Medicare is allowing. The Plan denied your request. The 
Plan says the claim was processed accordingly with your 2020 EOC 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. 
 
Review of the file show that you received the dental services on February 18, 2020 by an out-of-network 
provider. Your claim was processed accordingly to your benefits listed in your EOC. Your EOC states, 
"providers are paid based on Maximum Allowable Charge (MAC).  For services covered under the plan, you 
may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the 
plan to the provider." Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - 
established patient (D0120),  prophylaxis - adult (D1110), intraoral - periapical first radiographic image 
(D0220) and bitewings - four radiographic images (D0274) provided on February 18, 2020 by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested behavioral health therapy. 
 
You asked the Plan to pre-approve the behavioral health therapy. You say that you last saw this therapist in 
2017 and you do not want to see a new therapist. The Plan denied your request. The Plan says out- of-network 
providers are available only when your medical group does not have the appropriate expertise in their network. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue is a Marriage Family Therapist. A Marriage 
Family Therapist is not eligible to participate in the Medicare program. Therefore, we decided that the Plan 
does not have to pre-approve the requested behavioral health therapy.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee can have services at home, or an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not have 
complex wound care or other ongoing SNF level skilled nursing need. He does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. He does not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this 
enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 therapy at an inpatient rehabilitation facility would be better for your. The Plan denied your request. The Plan says that you do not need three hours a day of therapy and your medical illnesses are stable and do not need a physician to monitor this three times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve the wheelchair accessory. You say that please reconsider the this request 
because this power seat is needed for the wheelchair because a normal wheelchair will not work. It is too low to 
the ground and he cannot get out it. The Plan denied your request. The Plan says this item is not primarily 
medical in nature and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessory have not been met. Therefore, we decided that the Plan does not have to 
pre-approve wheelchair accessory, power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture (D5226). 
 
You asked the Plan to pre-approve the lower partial denture. You say that you had to stop wearing your old 
partials because it was causing pain, swelling and bleeding. The metal plate base partial does not work you 
need the flexible base option. The Plan denied your request. The Plan says this service exceeds the benefit 
frequency. 
 
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. This service is covered once 
every 5 years. The records show that this service was provided 04/02/2019. 
 
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 
lower partial denture (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Retacrit injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is unknown if Retacrit is being used to reduce transfusion-related risks. 
 
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 the injection. Our reviewer says that the 
services at issue in this case are not medically reasonable or necessary. Our physician reviewer found the 
enrollee is reported to have established diagnoses of anemia, CKD, and folic acid deficiency. It appears that the 
enrollee is now seeing a new provider, who has requested Procrit/Retacrit, based on the fact that the enrollee 
was previously taking the drug. No records have been submitted showing that the enrollee has been evaluated, 
by either his prior or current provider, to exclude GI bleeding, iron deficiency or B12 deficiency. AS such, the 
requested drug is not currently shown to be medically necessary or reasonable. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Retacrit injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents (D4381) and 
scaling in presence of generalized moderate or severe gingival inflammation (D4346). 
 
You asked the Plan to pre-approve the localized delivery of antimicrobial agents and scaling. You say that you 
are unable to eat solid food, and you cannot chew because of the pain in your gums. The Plan denied your 
request. The Plan says these services are not covered. 
 
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 
localized delivery of antimicrobial agents (D4381) and scaling in presence of generalized moderate or severe 
gingival inflammation (D4346).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for computed tomography, thorax; with 
contrast material(s) (71260) provided on April 14, 2020 by an in-network provider. 
 
You asked the Plan to waive the coinsurance for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received a computed tomography, thorax; with contrast material(s) (71260) on 
April 14, 2020 performed by an in-network provider. The Medicare-allowed amount for the service is less than 
the set $375 copayment; therefore, you have been asked to pay the lesser amount of $184.27 for the service. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for computed tomography, thorax; with contrast material(s) 
(71260) provided on April 14, 2020 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says 
this service is allowed one time every 60 months. The Plan also says that the enrollee received this service less 
than 60 months ago. 
 
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, maxillary dentures are limited to once 
per 60 months. The record shows that the enrollee received a maxillary partial denture (D5211) on October 2, 
2019 and the enrollee's maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve a maxillary partial denture (D5211).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cup holder accessory for wheelchair 
 
You asked the Plan to pre-approve the cup holder accessory. You say that please see the attached 
documentation for a repair to the client owned power wheelchair. The Plan denied your request. The Plan says 
this service is not covered under the plan benefits. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the cup holder accessory for wheelchair
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from March 
17, 2020 at 9:44am through March 18, 2020. 
 
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our physician 
reviewer found the treating physician did not document that the patient was unstable for discharge/transfer on 
any date. The clinical documentation suggested that the patient was stable for transfer by ambulance to an in-
network hospital on March 17, 2020 at 9:42 am. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care provided to the enrollee from March 17, 2020 at 9:44am 
through March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic adjustments. 
 
You asked the Plan to pre-approve the chiropractic services. You say that this should be approved. The Plan 
denied your request. The Plan says the enrollee has no subluxation shown on x-ray imaging. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The x-ray report provided does not show any subluxation for which chiropractic care can be covered. 
Therefore, we decided that the Plan does not have to pre-approve chiropractic adjustments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve a walk-in bathtub. You say that this is medically necessary for you. The 
Plan denied your request. The Plan says that this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift chair. 
 
You asked the Plan to pre-approve a power seat lift chair. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above 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 power seat lift chair. Our reviewer 
says that the documentation does not support that the requested Power Lift Recliner is medically reasonable or 
necessary. Our physician reviewer found you have arthritis and leg pain. The documentation supports that you 
can ambulate without an assistive device. You can transfer without difficulty from a sitting to standing 
position. No shortness of breath noted during the assessment and you reported you have no shortness of breath. 
You presented with no mobility or position change limitations and is independent with all transfers in her 
home. The documentation does not support that the seat lift is likely to effect improvement in your condition or 
arrest or retard deterioration in your condition. Therefore, you do not meet criteria for the requested item. 
 
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 power seat lift chair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat lift chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician?s intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, cervical; without 
contrast material (72141). 
 
You asked the Plan to pre-approve the MRI. You say that you are asking for a MRI. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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. Our physician reviewer found 
based on the medical records provided there is no documentation that the MRI without contrast of the cervical 
spine is medically reasonable and necessary. The patient does not have any signs or symptoms suggesting a 
more serious problem (such as infection, malignancy or spinal cord impingement) and the patient has not failed 
a six week trial of physician directed treatment. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, spinal canal and contents, cervical; without contrast material (72141).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on February 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient services provided on February 27, 
2020 by an out of network (OON) provider.