Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 17, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is 
important to know which providers are part of our network because, with limited exceptions, while you are a 
member of our plan you must use network providers to get your medical care and 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 did not pre-approve the 
physician?s services. 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 physician's services provided on February 17, 2020.
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 needs a hospital level of care for rehab 
with close medical management. The Plan denied your request. The Plan says the enrollee does not have any 
acute or new medical conditions. 
 
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 is at an independent assist level for eating, setup for grooming, moderate to total assist for 
bathing, total assist for dressing, and total assist for toileting. The enrollee does not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. 
 
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 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 rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2392) provided on July 7, 2020. 
 
You asked the Plan to pay for the dental service. You say that the service was medically necessary to prevent 
more complications. You say that you are more prone to infection. You say that you needed to filling to prevent 
a possible future infection. You also say that fillings are a preventive service and should be covered. The Plan 
denied your request. The Plan says the filling is not 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the filling you received is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling 
(D2392) provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality test (D0460) and the root canal (D3330) 
provided. 
 
You asked the Plan to pay for the dental services. You say that you received necessary dental surgery services. 
You also say that the services should be covered by your plan. The Plan denied your request. The Plan says 
vitality test is not listed as a covered service. The Plan says root canal is not listed as a covered service either. 
The Plan says any services not listed are not covered. The Plan also says that the services you received are 
dental in nature. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. However, your 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 pulp vitality test and root canal are 
not among those covered under this benefit. Additionally, 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 either. Therefore, we decided 
that the Plan does not have to pay for the pulp vitality test (D0460) and the root canal (D3330) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown, and prefabricated post and core. 
 
You asked the Plan to pre-approve the dental services. You say that you have a difficult time chewing without 
the crowns. The Plan denied your request. The Plan says a post and core are not a covered benefit, and you 
have exceeded the benefit for a crown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The file shows a dental crown was requested for tooth #12. We looked at the file and the rules. The records 
show that you previously received this service on November 16, 2015. The service is only covered once per 60 
months. Based on this information, we decided the Plan's coverage rules have not been met.  
 
The file shows a dental crown was requested for tooth #13. We looked at the file and the rules. In this case, 
there is insufficient records to show that the requested crown is needed for tooth #13. Based on this 
information, we decided the Plan's coverage rules have not been met.  
 
The file shows that a prefabricated post and core were requested for teeth #12 and 13. Although the Plan offers 
a dental benefit in excess of Medicare coverage, the requested service is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve a dental crown, and prefabricated 
post and core.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic testing panel provided on May 14, 
2020. 
 
You asked the Plan to pay for the genetic panel. You say that this testing should be covered due to medical 
necessity. The Plan denied your request. The Plan says this is not coded correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. 
 
In this case, we find that the plan's citations regarding the coding of these tests are not applicable. However, 
this was not ordered by a network provider and no medical records were submitted to support that this testing is 
medically reasonable and necessary for diagnosis or therapeutic decision-making. Without medical records 
from the ordering provider, it cannot be confirmed that Medicare coverage rules have been met. Therefore, we 
decided that the Plan does not have to pay for the cardiovascular genetic testing panel provided on May 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. 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 subsequent nursing facility visit (99308) provided, 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forthe  psychiatric  diagnostic  evaluation  (90791) provided  on June  16, 2020 by an out  of network  (OON) provider.You asked the  Plan to pay  forpsychiatric  diagnostic  evaluation.  You  say that the services  rendered were medically  necessary.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 forthe psychiatric  diagnostic  evaluation  (90791) provided  on June  16, 2020 by an out  of network  (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you are an independent laboratory and perform the 
ordered tests. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with 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 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 June 11, 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 a flex-walk system. 
 
You asked the Plan to pre-approve the flex-walk system. You say that you would like reconsideration because 
this equipment is medically necessary to prevent foot wounds. The Plan denied your request. The Plan says the 
member's functional level is K2. 
 
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 flex-walk system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the flex-walk system is covered for patients whose functional level is 3 or above. The 
member is a K2 ambulator. 
 
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 flex-walk system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a flex-walk system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an 
ambulatory surgical center on February 19, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you have had this 
service in the past and it was covered in full. The Plan denied your request. The Plan says you were charged 
this copayment 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 a $315 
copayment for diagnostic colonoscopies at an ambulatory surgical center.  
 
You have been asked to pay a $315 copayment for the diagnostic colonoscopy. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the diagnostic colonoscopy you had at an ambulatory surgical center on February 
19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the information did not show the need for continued skilled 
therapy services, continued care for complex medical needs, complicated wound care , or antibiotics through 
the enrollee's veins. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of Zoledronic acid is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record does not a show a trial of the plan preferred 
drug or any reason the plan preferred drug would be unsafe or ineffective for 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from July 21, 
2020 through July 29, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that this was required physical 
therapy for recovery from a hip replacement. You say that this should be covered without a copayment. The 
Plan denied your request. The Plan says the copayments applied 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 a $30 
copayment for physical therapy provided at an in-network specialist's office, outpatient hospital or 
comprehensive outpatient rehab facility.  
 
You have been asked to pay a $30 copayment for each physical therapy visit. The total amount you owe is 
$120 ($30/visit x 4 visits = $120). Physical therapy falls within the "Outpatient rehabilitation services" 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 physical therapy provided from 
July 21, 2020 through July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on 
June 2, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. 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 subsequent nursing facility visit (99309) 
provided on June 2, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records did not describe a recent six week trial of conservative therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found a review of the records 
shows a very brief neuro exam and no red flags such as absent or diminished reflexes. Her plain films of the 
pelvis show no fracture.  Her presumptive diagnosis is left sacro ileitis. She has not attempted conservative 
therapy including PT.  She has not had a nerve conduction or EMG study. The medical necessity of MRI 
without first trying PT has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the lumbar spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on 
December 2, 2019, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. 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 subsequent nursing facility visit (99309) 
provided on December 2, 2019, by an out-of-network (OON) provider.