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

 
We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve this service. You say that an inpatient skilled nursing facility admission is 
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an 
inpatient skilled nursing facility admission. 
 
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 this service. Our reviewer says an 
inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that you 
do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do not meet 
severity of illness or intensity of service criteria for 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not a covered benefit. 
 
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 core 
buildup.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the duplex scan shows that the targeted veins are larger than 4mm in diameter. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
procedure in question. Coverage requires that the enrollee's signs and symptoms be attributable to the veins 
selected for treatment. It is not possible to attribute leg discomfort and skin changes in this enrollee without an 
assessment of lower extremity arterial perfusion. More importantly - it is not possible to determine the medical 
necessity and appropriateness of the requested surgery without an assessment of lower extremity arterial 
perfusion. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says care is not complex enough, and the care can be received in a lower 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 there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) chemotherapy in the setting of a 
clinical trial. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says clinical trials are covered by Original Medicare. 
 
The Plan must follow Medicare rules. the rules say that Original Medicare is responsible for the costs 
associated with clinical trials. 
 
We looked at the file and Medicare rules. The file shows that the services are being requested in the setting of a 
clinical trial. Services rendered as part of a Medicare-approved clinical trial are covered by Original Medicare, 
not the Plan. 
 Therefore, we decided that the Plan does not have to pre-approve intravenous (IV) chemotherapy in the setting 
of a clinical trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says radiation oncology and imaging studies can be provided within the 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 
a referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Freedom Lite test strips. 
 
You asked the Plan to pre-approve the requested supplies. You say that you would like the meter that you can 
stick your forearm and still get an accurate reading. The Plan denied your request. The Plan says there is no 
reason you cannot use the preferred choice brand. 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred, or may limit the DME to only those preferred brands and manufacturers. 
 
We looked at the file, and Medicare rules. The documentation in the case file does not indicate that the 
preferred brands would not be effective, or cannot be used. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve FreeStyle Freedom Lite test strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye injection and does not have to waive 
the coinsurance for a Medicare Part B drug provided on February 20, 2020. 
 
You asked the Plan to waive the copayment for an eye injection and to waive the coinsurance for a Medicare 
Part B drug. You say that you only received one injection, not two, and disagree with the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
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 $20 
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received an eye injection on February 20, 2020. Therefore, you are responsible to pay the $20 copayment 
for specialist services.  
 
You received a Medicare Part B drug on February 20, 2020. The allowed amount is $225 and 20% of that is 
$45.  
 
The total amount you owe is: $65.  
 
You have been asked to pay the total copayment amount of $65 for an eye injection and a Medicare Part B 
drug. An eye injection falls within the physician/practitioner services, including doctor's office visits benefit 
category. A Medicare Part B drug falls within the Medicare Part B prescription 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 copayment for an eye injection and does not have to waive the coinsurance 
for a Medicare Part B drug provided on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies provided from August 14, 2019 to 
September 10, 2019. 
 
You asked the Plan to pay for the infusion supplies (A4221, A4222). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says there is no itemized shipping/billing invoice to indicate the 
specific supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. There is no itemized 
delivery ticket or itemized shipping invoice in the file. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the infusion supplies provided from August 14, 2019 to September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cardio Mems Heart Failure System (CPT 33289). 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the study requested is not covered by the member's health plan and this procedure has 
not been shown to be safe and effective and is considered investigational and experimental. 
 
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 item. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has 
been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy.  
Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not 
met since the device should still be considered experimental or investigational. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Cardio Mems Heart Failure System (CPT 33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) 
and first intraoral periapical x-ray (D0220) provided on April 24, 2020. 
 
You asked the Plan to pay more for the problem focused limited oral evaluation and first intraoral periapical x-
ray. You say that you were informed that these services would be covered 100% with no copay. The Plan 
denied your request. The Plan says these services were covered at 50% of the billed charges. 
 
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 
listed as covered services, and the Plan paid a portion of these services. Therefore, we decided that the Plan 
does not have to pay more for the problem focused limited oral evaluation (D0140) and first intraoral periapical 
x-ray (D0220) provided on April 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays- four radiographic images (D0274) provided 
on June 10, 2020. 
 
You asked the Plan to pay for bitewing x-rays- four radiographic images (D0274). You say that you received a 
notice of denial and would like to dispute the case. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 
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 bitewing 
x-rays- four radiographic images (D0274) provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic pillow. 
 
You asked the Plan to pre-approve an orthopedic pillow. You say that you need an orthopedic pillow so you 
can sleep well and improve your health. The Plan denied your request. The Plan says an orthopedic pillow is a 
convenience item not primarily medical in nature. 
 
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 an orthopedic pillow.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional group psychotherapy sessions. 
 
You asked the Plan to pre-approve more group psychotherapy sessions (90853). You say that the enrollee is 
struggling and needs more outpatient services. The Plan denied your request. The Plan says they will approve 
12 visits but more visits are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve more group psychotherapy sessions 
(90853). Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found that this enrollee has shown some depression and anxiety but not 
intense. This enrollee did not show severity of symptoms as noted in the record. Based on review the records 
provided, this enrollee does not require additional treatment sessions based on the documentation and severity 
of symptoms. The medical plans authorization for 12 visits appears generous for the treatment of this enrollee. 
Additional visits do not appear to meet the criteria for reasonable or medical necessity for the treatment of this 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of more group psychotherapy sessions (90853) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional group psychotherapy sessions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97014, 97140, 97035 and 29260) 
provided on April 13, 2020 through May 12, 2020. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration 
because this provider is a licensed physical therapist and you were told these services would be covered. The 
Plan denied your request. The Plan says physical therapy services are not covered when performed by a 
chiropractor. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical therapy services (97014, 97140, 97035 and 29260) provided on April 
13, 2020 through May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on November 13, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for vision services. You say that you do not have the money to pay this. You say that 
you did not know that this provider was out-of-network. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that the member's primary care physician did not refer these 
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 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 vision services provided on November 13, 2019 
by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging services provided from 
June 13, 2020 to June 14, 2020. 
 
You asked the Plan to waive the copayment for advanced imaging services. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 $225 
copayment for advanced imaging services.  
 
You have been asked to pay a $225 copayment for advanced imaging services. Advanced imaging services 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 advanced imaging services provided from June 13, 2020 to June 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided by an out-of-network 
provider on May 27, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the services were not urgent, emergent, or approved in advance. 
 
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 outpatient hospital services provided by an out-of-
network provider on May 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a hysterectomy (58260) 
provided on December 12, 2019 by a certified surgical assistant. 
 
You asked the Plan to pay for surgical assistant services. You say that this was ordered by the in-network 
surgeon to ensure the enrollee's safety. The Plan denied your request. The Plan says this is not covered when 
provided by a CSA. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a 
hysterectomy (58260) provided on December 12, 2019 by a certified surgical assistant.