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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and a hydraulic patient lift 
for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 items. Our reviewer says that the 
requested items are not medically reasonable or necessary. Our physician reviewer found the documentation 
does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an 
ordinary bed or why positioning of the bed in other ways is not feasible. The documentation indicates the 
patient enrollee turning every 2 hours, but the documentation does not specify that the enrollee is unable to 
reposition herself. The documentation does not reveal the need for an immediate change in position. The 
documentation does not support the need for special attachments that cannot be fixed on an ordinary bed. The 
documentation is not clear that the enrollee can operate the controls of the bed and cause the adjustments. The 
medical progress notes do not clearly indicate that the enrollee would be bed-confined without a lift. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a semi-electric hospital bed and a hydraulic patient lift for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene analysis provided on September 25, 2019. 
 
You asked the Plan to pay for the service provided. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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 0032U-59 is COMT (catechol-O-methyltransferase)(eg, 
drug metabolism) gene analysis, c.472G>A (rs4680) variant. We find that CPT code 0032U-59 is not supported 
in the medical record. The medical records provided do not show that the service billed with the -59 modifier is 
a distinct procedural service.  Based on this information, we decided that Medicare rules for coverage of the 
service provided have not been met. Therefore, we decided that the Plan does not have to pay for the gene 
analysis provided on September 25, 2019.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a nasal endoscopy provided on May 15, 2020. 
 
You asked the Plan to waive the copayment for a nasal endoscopy. You say that you were only aware of the 
specialist copayment. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $45 copayment for specialist services.  
 
You received a nasal endoscopy on May 15, 2020. A nasal endoscopy is considered a surgical procedure. Since 
the procedure was provided by a specialist you are responsible to pay a $45 copayment. The record shows that 
you have already paid the $45 copayment for specialist services and are not appealing the specialist copayment.  
 
The Plan says you must pay a $25 copayment for a nasal endoscopy. Based on the Plan contract, however, you 
cannot be asked to pay more than a $45 copayment for specialist services. Therefore, we decided that the Plan 
has to waive the copayment for a nasal endoscopy provided on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for physician's services provided on February 18, 
2020 and March 23, 2020. 
 
You asked the Plan to reimburse you for the physician's services. You say that your primary care physician 
referred you to this provider. You say this provider is not a private provider but he is a specialist trained in the 
treatment of CIRS. The Plan denied your request. The Plan says the health Plan will not reimburse you for 
charges incurred by Medicare opt out providers. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to 
reimburse you for physician's services provided on February 18, 2020 and March 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says you do 
not have skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found that you are able to attend in-person, outpatient office visits on her own. As such, you do not 
appear to be homebound. Therefore, home health services are not shown to be medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider from January 31, 2020, to February 7, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
from January 31, 2020, to February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup, including any pins when 
required provided on January 28, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were under the impression that you 
had dental coverage. The Plan denied your request. The Plan says you received these services before your 
plan's coverage began. The Plan also says that your dental policy did not go into effect until March 1, 2020. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the crown and core buildup, 
including any pins when required provided on January 28, 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. 
 
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 you can safely receive the services you need 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that your functional status requires 
or could tolerate an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of disrupted collateral ligament of ankle for the 
enrollee. 
 
You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no clinical information submitted by the provider to support the request for the 
appeal. 
 
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 repair. Our reviewer says that the 
requested repair is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the progress notes do not contain an extensive ankle physical exam, or information of imaging that 
would confirm ankle ligament disruption in need of repair. 
 
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 repair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve repair of disrupted collateral ligament of ankle for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the device is not covered for this use. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested item is not medically necessary. Our physician reviewer found the requested 
device has features that are determined deluxe and provide function which replaces rather than improves the 
function of the enrollee's arm.  The device is considered experimental. Medicare guidelines are not met. 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care rendered by the out of network 
(OON) provider from November 6, 2019 to November 12, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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. 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 the inpatient hospital care rendered by the out of network (OON) provider from 
November 6, 2019 to November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5225) provided on January 
28, 2020. 
 
The Enrollee asked the Plan to pay for the maxillary partial denture. The enrollee said that they were under the 
impression that they had embedded comprehensive dental coverage. The Plan denied the enrollee's request. 
The Plan says this service is not a covered benefit under the enrollee's dental 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 pay for the 
maxillary partial denture (D5225) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by an out 
of network provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request prior authorization. 
 
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 medical services provided on August 21, 2019 
by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic therapy (D3330) 
for tooth #14 and #15. 
 
You asked the Plan to pre-approve the core buildup and endodontic therapy services. You say that you are in 
extreme pain and that the requested services are medically necessary. The Plan denied your request. The Plan 
says the services being requested are non-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 core 
buildup (D2950) and endodontic therapy (D3330) for tooth #14 and #15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lifeline device with GPS for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that telephone alert systems are excluded from coverage as 
these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. 
 
Although this device may be appropriate, it is not covered by Medicare. Therefore, we decided that the Plan 
does not have to pre-approve a Lifeline device with GPS for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to 
verify eligibility and obtain proper authorization. The Plan denied your request. The Plan says a prior 
authorization was not provided as required by 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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided on May 6, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires aggressive therapy and close 
physician monitoring, The Plan denied your request. The Plan says the enrollee does not require frequent rehab 
physician management, or an interdisciplinary approach to rehab 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 physician reviewer found 
that the enrollee was admitted to the acute hospital for weakness and falls. The complexity of the enrollee's 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that he will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  The 
medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you feel the enrollee meets Medicare criteria for 
acute inpatient rehab, and will benefit from the acute inpatient rehab that cannot be accomplished at a lower 
level of care. The Plan denied your request. The Plan says the IRF services are 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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.