Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection (CPT Code E0694).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan for the member's diagnosis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Medicare only covers this item for beneficiaries with generalized intractable psoriasis. The Plan states the member does not have this diagnosis. Therefore, we decided that the Plan does not have to pre-approve ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer and eye protection (CPT Code E0694).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a sacral fracture after a fall. Medical problems are stable. There are no identified problems that need inpatient medical management. 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. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 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.

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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (43248). 
 
You asked the Plan to pre-approve esophagogastroduodenoscopy. You say that attached are updated medical 
necessity form and office notes. The Plan denied your request. The Plan says the submitted documentation does 
not show evidence of gastrointestinal bleeding. 
 
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 esophagogastroduodenoscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found EGD and colonoscopy are ordered for performance in tandem. The last 
colonoscopy dates to 2013, and showed diverticulosis and colon polyps. LCD criteria require that colonoscopy 
first prove negative for a source of GI bleeding. This criteria has not been met per provided records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of esophagogastroduodenoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve esophagogastroduodenoscopy (43248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required. 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is 
not covered under your benefit plan. 
 
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 a 
core buildup, including any pins when required.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on May 14, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you cannot afford 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 $400 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $400 copayment for an EGD. An EGD falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on May 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (80053 and 85025) 
received on January 29, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you were never informed of a 
copayment. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $10 
copayment for Medicare-covered lab services.  
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services (80053 and 85025) received on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine provided on May 27, 2020. 
 
You asked the Plan to pay for a shingles vaccine under Medicare Part B. You say that the Plan should pay for 
this vaccine. The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine 
under Medicare Part B. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine 
under Medicare Part B. Therefore, we decided that the Plan does not have to pay for a shingles vaccine 
provided on May 27, 2020.  
 
Benefits for a shingles vaccine under Medicare Part B 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided to you on October 29, 2019. 
 
You asked the Plan to pay for the lab services. You say that this should be covered. The Plan denied your 
request. The Plan says that these services are not covered. 
 
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. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided to you on 
October 29, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge (D6241) and crown lengthening 
(D4249). 
 
You asked the Plan to pre-approve a dental bridge and crown lengthening. You say that you need these services 
and cannot afford them. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental bridge (D6241) and crown lengthening (D4249).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consult to be provided at an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 physician reviewer found adenocarcinoma of esophagus 
can be treated by in-network providers. 
 
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.  
 
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 the services. Therefore, we decided that the Plan does 
not have to pre-approve an office consult to be provided at an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care provided from October 8, 2020, 
forward. 
 
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 there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care provided from October 8, 2020, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal for a molar (D3330) and treatment of a root 
canal obstruction (D3331). 
 
You asked the Plan to pre-approve the dental services. You say that you have been taking pain medicine for 
months. You say that you would like for your tooth to be saved. You say that if you get the tooth removed, it 
will affect your other teeth. You also say that you cannot afford all the funds. The Plan denied your request. 
The Plan says root canal for a molar is not listed as a covered service. The Plan also says that treatment of a 
root canal obstruction is not listed as a covered service. 
 
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 a 
root canal for a molar (D3330) and treatment of a root canal obstruction (D3331).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on February 19, 2020. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says this service is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient, is covered by the prospective payment rate 
or reimbursed as reasonable costs under Part A to hospitals excluded from PPS. 
 
We looked at the file and Medicare rules. Payment for the requested ambulance transportation is included in 
the payment for the inpatient care and is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the transportation have not been met. Therefore, we decided that the Plan does 
not have to pay for the ambulance transportation provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 5, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional quantities of headgear (A7035) and chinstrap 
(A7036). 
 
You asked the Plan to pre-approve the supplies. You say that these supplies are needed. The Plan denied your 
request. The Plan says the requested additional quantity of supplies is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that A7035 and A7036 are covered once every six months. 
 
The requested rate of supply of once every three months for these CPAP accessories are not in line with 
Medicare guidelines. These supplies are meant to be supplied once every six months. Based on this 
information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional quantities of headgear (A7035) and chinstrap 
(A7036).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions 
provided on May 20, 2020, by an OON provider. 
 
You asked the Plan to pay for the alveoloplasty. The Plan denied your request. The Plan says the service was 
rendered by an OON provider. The Plan also says that your responsibility will be higher when the provider is 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the alveoloplasty not in conjunction with extractions provided on May 20, 2020, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on June 23, 2020. 
 
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that this wasn't a 
surgery in your opinion. You say that was done in the radiology department. The Plan denied your request. The 
Plan says the correct copayment has been applied. 
 
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 outpatient surgery.  
 
You have been asked to pay a $50 copayment for a fine needle aspiration biopsy. The service that was provided 
to you is considered an outpatient surgery. A fine needle aspiration biopsy falls within the outpatient surgery 
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 outpatient surgery provided 
by a participating provider on June 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90832) provided on May 30, 2020, 
through August 7, 2020. 
 
You asked the Plan to pay for the psychotherapy. You say that you were not aware of prior authorization 
requirements. The Plan denied your request. The Plan says this service is not covered by Medicare or your 
plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Part B covers mental health services with 
specific types of health professionals. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the requested provider is a Qualified Mental 
Health Professional. This provider type is not eligible for Medicare coverage of mental health services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) provided on May 30, 
2020, through August 7, 2020.
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 receive the care needed in 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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for acute on chronic 
cholecystitis and had cholecystectomy. The enrollee's medical problems are stable. There are no identified 
problems that need inpatient medical management. 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. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy 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.