Persius/hicric huggingface dataset:
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 and 
does not require transfer to LTACH. 
 
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 
hospital. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injection you received. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that you would like help 
with this bill. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the aflibercept injection. The aflibercept injection falls within 
the Medicare Part B drugs 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 coinsurance for the 
aflibercept injection you received.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged home service provided on June 18, 2019. 
 
You asked the Plan to pay for the prolonged home service. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the records do not support services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99354 is prolonged evaluation and management or 
psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other 
outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in 
addition to code for office or other outpatient Evaluation and Management or psychotherapy service).  
 
 
We find that the addition CPT code 99354 is not supported in the medical record. Specifically, the medical 
records provided show the service was provided by a Physical Therapist, not the billing physician. Based on 
this information, we decided that Medicare rules for coverage of the addition code of prolonged home services 
have not been met. Therefore, we decided that the Plan does not have to pay for the home visit and prolonged 
home service provided on June 18, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the root canal. We decided that the Plan does not have to pre-
approve the periodontal scaling and root planing for 2 quadrants.  
 
You asked the Plan to pre-approve the root canal. You say that the dental services are medically necessary. The 
Plan says that root canal is not listed as a covered service. The Plan says periodontal scaling and root planing, 1 
to 3 teeth per quadrant, is not listed as a covered service either. The Plan also says if a dental item or service is 
not listed in the benefit chart or listed with NC, then it is not covered. 
 
 
 
 
We decided that the Plan has to pre-approve the root canal.  
 
Root canal is listed in the Customer Handbook as a covered service. Therefore, we decided that the Plan has to 
pre-approve the root canal.  
 
We also decided that the Plan does not have to pre-approve the periodontal scaling and root planing for 
2 quadrants. 
 
Periodontal scaling and root planing, 1 to 3 teeth per quadrant is not listed as a covered service. Therefore, we 
decided that the Plan does not have to pre-approve the periodontal scaling and root planing for 2 quadrants. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 you do 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. Your functional level is near 
baseline and 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. 
You do 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, you do 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. 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 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 implants (D6010), 2 custom fabricated abutments 
(D6057), and 2 abutment supported crowns (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist advised you needed to have 
the dental implants only for the front 2 studs on the lower plate because you do not have enough bone left to 
hold a regular denture in place. You say that you do not have enough bone in the back of your lower jaw to 
even implant the rear studs but the denture can be secured to the front 2 studs. You also say that you are having 
trouble with your stomach and maintaining your weight because you cannot properly chew your food. The Plan 
denied your request. The Plan says implant is not listed as a covered service. The Plan says that custom 
fabricated abutment is not listed as a covered service. The Plan says that custom fabricated abutments is not a 
covered service either. 
 
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. Additionally, the Evidence of Coverage clearly states that any services 
not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve 2 implants 
(D6010), 2 custom fabricated abutments (D6057), and 2 abutment supported crowns (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you dropped your lower denture which broke 
in half and half went down the drain. You also say that your dentist advised you need a new denture due to 
serious recession of gums. The Plan denied your request. The Plan says dentures are covered once every 5 
plan years. The Plan says that the frequency limit has been reached. 
 
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 and dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that you previously received 
dentures on October 17, 2017. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing frame/table system. 
 
You asked the Plan to pre-approve a standing frame/table system (E0642). You say that you benefit from a 
standing frame/table system but your current standing frame is falling apart due to constant use. The Plan 
denied your request. The Plan says a standing frame/table systems are 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 standing frame/table system.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for infectious agent drug susceptibility (87900), analysis test 
by nucleic acid for HIV-1 virus (87901) and Analysis test by nucleic acid for HIV-1 virus, other region (87906) 
by an out-of-network provider on February 17, 2020. 
 
You asked the Plan to hold you harmless for infectious agent drug susceptibility, analysis test by nucleic acid 
for HIV-1 virus and Analysis test by nucleic acid for HIV-1 virus, other region. You say that you provided 
medically necessary services referred by another provider. The Plan denied your request. The Plan says that 
prior authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for infectious agent drug susceptibility, analysis test by nucleic acid for HIV-1 virus 
and Analysis test by nucleic acid for HIV-1 virus, other region by the provider. The provider is a contract 
provider. The file does not show that the plan provided notice that infectious agent drug susceptibility, analysis 
test by nucleic acid for HIV-1 virus and Analysis test by nucleic acid for HIV-1 virus, other region would not 
be covered. Under Medicare rules, this means infectious agent drug susceptibility, analysis test by nucleic acid 
for HIV-1 virus and Analysis test by nucleic acid for HIV-1 virus, other region is considered approved by the 
plan. Therefore, we decided that the Plan has to hold you harmless for infectious agent drug susceptibility 
(87900), analysis test by nucleic acid for HIV-1 virus (87901) and Analysis test by nucleic acid for HIV-1 
virus, other region (87906) by an out-of-network provider on February 17, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), tangential biopsy of skin (11102) 
and tissue exam by pathologist (88305)  provided on July 21, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit, biopsy of skin and tissue exam. You say that you were unaware this 
provider was out-of-network. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services rendered by an out-of-network provider. 
 
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 office visit (99204), tangential biopsy of skin 
(11102) and tissue exam by pathologist (88305)  provided on July 21, 2020 by an out of network (OON) 
provider.
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 these services are medically necessary. 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 does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the obstetrics and gynecology services (99000, Q0091, 
99203, 99387) provided on March 2, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the obstetrics and gynecology services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 obstetrics and gynecology services (99000, 
Q0091, 99203, 99387) provided on March 2, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Purewick System. 
 
You asked the Plan to pre-approve the Purewick System.. You say that you would like reconsideration because 
this equipment is medically necessary. The Plan denied your request. The Plan says this is not a Medicare 
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 the Purewick System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental item. You say that you need a night guard to prevent you from 
clenching your teeth at night. You say that without it you could break your crowns or teeth. You also say that it 
is in the plan's best interest to approve this item. The Plan denied your request. The Plan says an occlusal guard 
is not listed as a covered service under the preventive and diagnostic dental plan that you are enrolled in. 
 
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 
occlusal guard (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Power Wheelchair, Group 2 Standard (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are in bed all day because you are 
not mobile, and can only walk around 30 steps. The Plan denied your request. The Plan says you have a 
scooter, walker, and cane, and are able to stand and transfer independently and ambulate 240 feet with a four-
wheeled walker without loss of balance. 
 
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 power wheelchair. Our physician 
reviewer found the requested power wheelchair (K0823) is not medically necessary per Medicare's NCD 
280.3(B). The documentation does not reveal that you have a personal mobility deficit that impairs 
participation in MRADLs in the home. Your mobility deficit is currently helped by a front wheeled walker. 
While you may have the  cognition to safely operate a PMD the documentation does not support that you 
require the K0823 power wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Power Wheelchair, Group 2 Standard (K0823).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that does not require prior authorization. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 office visit (99213) provided by an out of 
network (OON) provider.