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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, and panoramic x-ray provided on October 14, 2020, by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
panoramic x-ray. You say that you were advised by the Plan that you could go to the facility this provider 
works at. The Plan denied your request. The Plan says the requested items or services are not covered when 
they are received OON. 
 
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 pay for the 
problem focused limited oral evaluation, first intraoral periapical x-ray, and panoramic x-ray provided on 
October 14, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) and 
complete bilateral duplex scan of extracranial arteries (93880) provided on May 20, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit and complete bilateral duplex scan of 
extracranial arteries. You say that you do not recall being seen on May 20, 2019, and you were not aware there 
would be a copayment. The Plan denied your request. The Plan says the copayments were applied 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 a $50 
copayment for diagnostic tests, and a $45 copayment for a specialist office visit. 
 
You have been asked to pay a $50 copayment for diagnostic tests, and a $45 copayment for a specialist office 
visit. A specialist office visit falls within the physician/practitioner services benefit category and a complete 
bilateral duplex scan of extracranial arteries falls within the outpatient diagnostic testing benefit category. 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 copayment for a specialist office visit (99214) and complete bilateral 
duplex scan of extracranial arteries (93880) provided on May 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 16, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered.  
 
We looked at the claim submitted, the file and the Medicare rules. Each RAP must report a payment group 
represented by a HIPPS code. In general, a RAP and a claim will be submitted for 
each episode or period of care. Each claim must represent the actual utilization over the episode period. If the 
claim is not received 60 days after the calculated end date of the episode (day 120) or period (day 90) or 60 
days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by 
Medicare claims processing systems. Based on this information, we decided that Medicare rules for completing 
the claim for home health services have not been met. Specifically, a final claim was not found to be submitted 
to the plan. Therefore, we decided that the Plan does not have to pay for the home health services provided to 
the enrollee from March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam tab 0.5mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication falls under Part D coverage. 
 
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 Lorazepam tab 0.5mg for 
the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be met at a lower level of care. 
 
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. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fosfomycin 3 GM Sachet. 
 
You asked the Plan to pre-approve the self-administered drug. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 Fosfomycin 3 GM Sachet.  
 
Benefits for the self-administered drug 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the MRI services. You say that the enrollee is unable to tolerate a traditional 
MRI and needs an open MRI. The Plan denied your request. The Plan says they have contracted providers who 
are able to provide the services the enrollee needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. Specifically, the Plan has an in-network 
provider who will perform the open MRI the enrollee requires due to their medical condition. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve the magnetic resonance imaging (MRI) to be provided by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you require the device. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the arthrocentesis provided on August 12, 
2020 and September 9, 2020. 
 
You asked the Plan to waive the copayments for the arthrocentesis. You say that your benefits state that you 
have a $0 copayment for outpatient surgery. You say you would have cancelled if you had known there was a 
$250 copayment for each service. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 a $250 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $250 copayment for the arthrocentesis on each date of service. The 
arthrocentesis falls within the "Outpatient Surgery and Other Medical Services at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers" benefit category. The record shows the arthrocentesis is considered a 
surgical procedure. 
 
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 copayments for the arthrocentesis provided on August 12, 2020 and 
September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2330), the initial periapical x-ray (D0220), the 
additional periapical x-ray (D0230), and bitewing x-rays (D0274), and the unspecified preventive service 
(D1999) provided on October 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised that your out of pocket cost 
would be $89.50. You say that you were charged an additional $405.60. You also say that a plan representative 
advised that your provider contacted them and were advised which services would be covered. The Plan denied 
your request. The Plan says two fillings per calendar year are covered. The Plan says that one set of bitewing x-
rays are covered per calendar year. The Plan says that one periapical x-ray is covered per calendar year. The 
Plan also says that the frequency limits for these services have been exceeded. The Plan also says that the 
unspecified preventive service is 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 frequency limits for the services 
that you received have been exceeded. The record shows that the Plan paid for two fillings that you received on 
March 5, 2020. The record shows that the Plan paid for a set of bitewing x-rays and a periapical x-ray that you 
received on February 25, 2020. Additionally, the record shows that you are not responsible for the charge for 
the unspecified preventive service. Therefore, we decided that the Plan does not have to pay for the filling 
(D2330), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and bitewing x-rays 
(D0274), and the unspecified preventive service (D1999) provided on October 1, 2020.  
  
Your complaint about being misled by your provider's office is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of 
IRF care. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
 The enrollee was admitted for syncopal episodes and was treated for herpes encephalitis and a stroke. The 
enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external electrocardiographic recording (more than 48 
hours, up to 21 days) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says as the frequency of the palpitations is daily, a 24 to 48 hour holter monitor will meet 
needs. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the records, the enrollee is having frequent palpitations several times daily. In this circumstance 
a 24-48 hour Holter monitor should be sufficient to record and arrhythmia. A more prolonged monitor is not 
medically necessary since the documentation does not support the patient is experiencing "infrequent 
symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias." 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve external electrocardiographic recording (more than 48 hours, up to 21 days) for the 
enrollee.
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 enrollee has not completed the full course in the hospital. 
 
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 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from January 1, 2020 to January 31, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. 
Therefore, we decided that the Plan does not have to pay for the services rendered from January 1, 2020 to 
January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of admission to the SNF the 
enrollee was medically stable and at their functional baseline. The enrollee did not require any skilled nursing 
or rehab services on a daily basis at an inpatient level of care. The enrollee did not require skilled therapy to 
establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any 
skilled services on an inpatient basis, at a SNF level of care at the time of admission. The enrollee did not have 
any parental medication, complex wound care or nutrition given via a feeding tube. The enrollee was medically 
stable without any acute exacerbations of chronic medical problems. The enrollee's physical function was at or 
near their baseline and they could have received further services at a lower level of care. The enrollee required 
droplet isolation due to COVID infection. Admission to a SNF for inpatient skilled care was not medically 
necessary. 
 
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 SNF care 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member is at risk of jeopardizing their maximum 
function. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed 
in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of 
a hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.