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

 
We decided that the Plan does not have to pay for the CT of the abdomen and pelvis provided on October 2, 
2019. 
 
You asked the Plan to pay for the CT. You say that you would like this claim paid at the contracted rate. The 
Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.  Therefore, 
we decided that the Plan does not have to pay for the CT of the abdomen and pelvis provided on October 2, 
2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 14, 2020 to February 17, 2020. 
 
You asked the Plan to pay for the SNF care. You say that the SNF care provided from February 14, 2020 to 
February 17, 2020 was medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for the SNF care provided from February 14, 2020 to February 17, 2020. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found this enrollee was admitted to the hospital after 
being found unresponsive. She was treated for low oxygen levels in her blood, worsening heart failure, fast 
irregular heartbeat, and an electrolyte imbalance causing her to have an altered state of awareness and thinking 
(cognition). On 2/14/2020, the enrollee's hemodynamics are stable. O2 saturation levels are also stable on up to 
3-liters of oxygen. Functionally, the enrollee was mostly supervised for care.  
 
The enrollee is, as of 2/14/20 mostly supervised for all care. The enrollee has no complex wound care needs, or 
IV medication requirements.  There are no nursing or therapy needs that are skilled, and warranting a SNF as 
opposed to a lesser level of care.  The enrollee's vital signs are stable and SNF 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from February 14, 2020 to February 17, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound (76641) provided on 
May 29, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $45 
copayment for Medicare-covered x-rays and ultrasounds.  
 
You have been asked to pay a $45 copayment for the ultrasound provided. 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 the breast ultrasound (76641) provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care provided on June 23, 2020. 
 
You asked the Plan to pay for the vision care. You say that you were not advised that you needed prior 
authorization to see an out-of-network provider. The Plan denied your request. The Plan says you must receive 
care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out 
of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan.  
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for vision care provided on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors. 
 
You asked the Plan to pre-approve the sensors. You say that you are unable to prick your fingers to test your 
blood sugar. The Plan denied your request. The Plan says that you do not meet criteria because you are not 
taking insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are covered 
when the above criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of the sensors have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre continuous 
glucose monitor sensors.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you no longer require skilled services. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you suffer from incontinence and are no 
longer able to get around yourself without constant assistance. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you need this for your leg pain. The Plan 
denied your request. The Plan says the requested provider is not in-network. 
 
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. 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 chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no extenuating circumstances that would render in-lab polysomnography 
medically necessary in preference to home sleep testing. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary and meet the applicable criteria. 
 
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 study. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found an attended PSG is considered reasonable and medically necessary for this patient.  You have known 
obstructive sleep apnea (OSA), but remain symptomatic despite treatment with a mandibular advancement 
device. It is not clear to the ordering physician whether your sleep symptoms are related to inadequately treated 
OSA, or to periodic leg movement disorder, or other causes such as depression. The Epworth score is only 5, 
lowering the level of suspicion for untreated OSA.  A home sleep test cannot assess leg movement disorder, 
and is less sensitive than an attended test for OSA. 
 
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 study have been met. Therefore, we decided that the Plan has to pre-approve 
a sleep study.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is needed for the remainder of the year 
to accommodate your physical therapy visits. The Plan denied your request. The Plan says this request exceeds 
the benefit limit for the transportation program. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult with an oral surgeon for extractions. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says consults and extractions provided by oral surgeons, periodontists, 
endodontists, other dental specialists or non-network general dentists 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. The Plan covers the dental 
services when the services are provided by a participating general dentist. 
 
The requested services are to be provided by an oral surgeon, not a general dentist. Based on this information, 
we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a consult with an oral surgeon for extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the SI joint for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary, as this procedure is 
less invasive procedure with proven efficiency. The Plan denied your request. The Plan says the medical 
research has not shown that the use of this kind of treatment improves outcomes. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found radiofrequency ablation used for sacro-iliac joint pain is considered not medically 
necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. The review 
has determined that the requested radiofrequency ablation of the SI joints in this case 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 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the SI joint for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim upper partial denture coded D5820. 
 
You asked the Plan to pre-approve the interim partial denture. You say that you believe that this should be 
covered due to necessity. The Plan denied your request. The Plan says this is not a covered service under the 
enrollee's dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
interim upper partial denture coded D5820.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urogynecology consultation and follow-up visit 
(99204, 99214) to be rendered by the out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says an in-network provider is available to render the 
requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
urogynecology consultation and follow-up visit (99204, 99214) to be rendered by the out of network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a history of right knee osteoarthritis. The documentation does not support that 
the enrollee has tried and failed Monovisc and Orthovisc. The documentation does not outline contraindications 
or reasons these medications were not considered. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested dental services for the enrollee. 
 
You asked the Plan to pre-approve dental extractions. You say that these dental services are necessary for the 
enrollee. The Plan denied your request. The Plan says medical necessity for these dental services has not been 
established. 
 
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 dental 
services. Our reviewer says that the requested dental services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is a request for surgical extractions of teeth #13, 22, 
23, 26 and 28.  The provided x-rays show an intact clinical crown of tooth #13 with about 45% bone loss.  #22, 
#23 and #26 also show intact clinical crowns with 50-60% bone loss. Tooth #28 shows moderate damage to the 
clinical crown and an endodontic lesion present with associated bone loss around the apex of the tooth. There is 
no support for the need of a surgical procedure for the removal of teeth #13,22,23 and 26 as there is a 
significant, it not a full amount of clinical crown remaining on each tooth  to allow for a forceps removal of 
these teeth.  #28 has more breakdown of the clinical crown, but also has an endodontic lesion with noted bone 
loss which would make a simple forceps extraction likely.  Initially the tooth would be expected to be able to 
be removed with standard procedures and not require removal of bone in order to remove the tooth.  Should the 
eventuality occur then the treatment rendered must be properly documented and then submitted as performed 
with documentation. Therefore, at the present time there is no medical necessity for surgical extractions of 
teeth #13, 22, 23, 26 and 28. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve/or pay for the out-of-network services. 
 
You asked the Plan to pre-approve/or pay for the out-of-network services. You say that you would like the Plan 
to reconsider your request. The Plan denied your request. The Plan says that the services are not covered. 
 
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 did not send a complete case file in order for us to 
determine if the services were denied correctly. We sent a request for this information with no response. The 
case file came in as a Pre-service; however, the file included a denied claim for payment. The Plan did not 
include a case summary or an appeal letter and there is no information to determine if the Plan's denial was 
appropriate. Therefore, we decided that the Plan has to pre-approve/or pay for the out-of-network services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denial for this is consistent with guidelines. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer remains experimental. More research is needed to show safety and efficacy. There is no spinal 
instability in this case. The device is not 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device for the enrollee.