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

 
We decided that the Plan does not have to pre-approve Tertiary ophthalmology care, by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. You say that you have been seeing this specialist for seven 
years and wish to continue. The Plan denied your request. The Plan says your plan requires you to receive care 
from providers who are part of your primary care physician's (PCP) specialty 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 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 the plan has retinal specialists 
available in its network. The documentation does not support that ophthalmology services with a tertiary care 
provider are medically reasonable and necessary for you in this case. 
 
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 Tertiary ophthalmology care, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the 
enrollee from June 8, 2020 through July 7, 2020. 
 
You asked the Plan to pay for the SNF services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that the enrollee did not require SNF 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition did 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from June 8, 2020 
through July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99215) provided. 
 
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was submitted with an invalid 
primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-
10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient visit have not been met. Specifically, diagnosis code F01.50 requires that the 
underlying condition be sequenced first. Therefore, we decided that the Plan does not have to pay for the 
outpatient visit (99215) provided.
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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care.  The patient does require physical therapy and occupational therapy services 
but based on the medical records provided the patient does not require an intensive inpatient rehabilitation 
therapy program. Based on the medical records provided there is concern that the patient will not be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF due to their 
cognition and endurance. Care at the skilled nursing facility level or in the home with home health services 
appears to be more appropriate in this case. 
 

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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the office visit, ankle x-ray and ankle brace 
provided on January 16, 2020. 
 
You asked the Plan to waive the cost for the office visit, ankle x-ray and ankle brace. You say that you were 
informed they couldn't treat you without doing a new x-ray and insurance would cover the brace. You say that 
you are appealing the bill. The Plan denied your request. The Plan says the cost share 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 $20 
copayment for services obtained from a specialist, a $30 copayment for each Medicare-covered standard x-ray 
service and 20% coinsurance for Medicare-covered benefits.  
 
 
  
 
 
You have been asked to pay a total of $68.80 for the office visit, ankle x-ray and ankle brace.  
 
Service Allowed Amount Standard Cost Member Liability 
Office Visit $121.57 $20 $20 
Ankle X-Ray $41.02 $30 $30 
Ankle Brace $94 20% $18.80 
TOTAL:   $68.80 
 
The office visit falls within the "Physician/Practitioner Services, Including Doctor?s Office Visits" benefit 
category. The ankle x-ray falls within the ?Outpatient Diagnostic Tests and Therapeutic Services and Supplies? 
benefit category. The ankle brace falls within the ?Prosthetic Devices and Related 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 cost for the office visit, ankle x-ray and ankle brace provided on January 
16, 2020.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve eight (8) home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 the documentation in the medical records shows that skilled therapy services continue to be 
required to effectively provide treatment, care, and/or services in order to improve your condition, or to 
establish/perform a maintenance program to maintain your condition and/or prevent deterioration. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve eight (8) home health physical therapy visits.  
 
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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or 
to require regular physician evaluation. The enrollees care needs can be met at a lower level of 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 refraction services (92015) provided July 30, 2020 
 
You asked the Plan to pay for the refraction services. You say that the eye refraction was medically necessary 
to determine the extent of your cataracts before surgery. The Plan denied your request. The Plan says the 
refraction was not completed as part of a routine eye exam and is therefore non covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services only when performed during a routine exam and performed by a 
network provider. 
 
We looked at the file and the Plan's rules. eye refraction is only covered when completed during a routine exam 
and performed by a network provider. Based on this information, we decided that the Plan's rules for coverage 
of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for 
refraction services (92015) provided July 30, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, problem focused limited oral 
evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, and prefabricated post and core 
in addition to crown provided on June 24, 2020 by an OON provider. 
 
You asked the Plan to pay for the endodontic therapy, problem focused limited oral evaluation, intraoral 
periapical x-rays, and prefabricated post and core. You say that you chose to see this provider for the root 
canal, and believe the services you received were necessary for the procedure. The Plan denied your request. 
The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization 
was not obtained. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy, problem focused limited oral evaluation, first intraoral periapical x-ray, additional intraoral 
periapical x-ray, and prefabricated post and core in addition to crown provided on June 24, 2020 by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that due to problems in the gums you had to 
remove all of your teeth and now you have serious problems chewing your food. The Plan denied your request. 
The Plan says you exhausted your 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. 
 
You exhausted your benefit because you received maxillary partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) (D5213) on April 10, 2018. Your EOC 
states, "Complete dentures (upper and lower) (One (1) upper complete and one lower complete denture every 
five years, including routine post-delivery care) or Partial dentures (upper and lower) (One upper and/or one 
lower partial denture every five (5) years, including routine post-delivery care)." Therefore, we decided that the 
Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on July 27, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the radiology 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 services at issue in this appeal. The Plan did not pre-approve the service 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 radiology services provided on July 27, 2020 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from December 3, 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. 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 SNF 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 continuation of SNF care from December 3, 2020, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on May 6, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
diagnostic radiology 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 diagnostic radiology services provided on May 6, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services provided on July 20, 
2020. 
 
You asked the Plan to pay for the emergency department services. You say that CMS allows Independent 
Freestanding Emergency Departments to provide care to Medicare and Medicaid beneficiaries during the 
COVID-19 Public Health Emergency. The Plan denied your request. The Plan says the facility is a non-
Medicare approved/certified freestanding emergency facility. 
 
The Plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services 
furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
There is no Medicare approved Hospital Enrollment Attestation documentation in the file. Therefore, we 
decided that the Plan does not have to pay for the emergency department services provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 20, 
2020. 
 
You asked the Plan to pay for the services. You say that you processed the specimen and reported findings 
back to the doctors. The Plan denied your request. The Plan says Medicare says non-urgent services should be 
from network providers who are contracted with the healthplan and listed in the Provider Directory. 
 
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 laboratory services provided to the enrollee on 
February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synagis. 
 
You asked the Plan to pre-approve Synagis. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Synagis. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Pavlizumab (Synagis) is not FDA 
approved for the treatment of gastric cancer and is not supported by the major drug compendia for this 
indication. The medical literature does not support use in patients with metastatic gastric cancer. The provided 
documentation does not indicate a rationale for this medication. The service is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synagis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synagis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture. 
 
You asked the Plan to pre-approve the denture. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service exceeds the max allowable within a sixty month time frame. 
 
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. The Plan covers dentures once 
every sixty months. 
 
The records show that dentures were received less than sixty months ago. Based on this 
information, we decided that the Plan's rules for coverage of the denture have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower partial denture.