Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from January 6, 
2020, through May 4, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided from January 6, 2020, 
through May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four alveoloplasties in conjunction with extractions, a 
complete maxillary denture, and a complete mandibular denture. 
 
You asked the Plan to pre-approve the alveoloplasties, complete maxillary denture, and complete mandibular 
denture. The Plan denied your request. The Plan says these services are 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 four 
alveoloplasties in conjunction with extractions, a complete maxillary denture, and a complete mandibular 
denture.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an abdominal CT scan (74170). 
 
You asked the Plan to pre-approve an abdominal CT scan. You say that you started with a renal ultrasound but 
the result was unrevealing. The Plan denied your request. The Plan says that rules for pre-approval for a CT 
scan have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 an abdominal CT scan. Our reviewer 
says that a CT scan of the abdomen with and without contrast is medically reasonable and necessary. Our 
physician reviewer found a complete retroperitoneal ultrasound was performed on September 9, 2020, and was 
unremarkable. The Plan has denied coverage of the requested CT, stating that an ultrasound of the abdomen, to 
include the liver, gallbladder, spleen, pancreas, and kidneys, is reasonable for evaluation prior to proceeding 
with a CT. The documentation supports that a CT scan of the abdomen with and without contrast is medically 
reasonable and necessary for the enrollee in this case, following an unremarkable retroperitoneal ultrasound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an abdominal CT scan have been met. Therefore, we decided that the Plan has 
to pre-approve an abdominal CT scan (74170).  
 
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 osseous surgery (D4261). 
 
You asked the Plan to pre-approve osseous surgery (D4261). You say that x-rays revealed bone loss and 
scaling that needed to be done. You say that insurance should pay for 50% of the cost. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4261).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza by PCR testing provided on January 21, 2020. 
 
You asked the Plan to pay for the PCR flu testing. You say that this testing should be covered. The Plan denied 
your request. The Plan says this testing is not covered by Medicare. 
 
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 pay for the PCR flu testing. Our reviewer says that 
the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case the reviewed documentation revealed no report of respiratory symptoms and the clinical 
suspicion was a urinary tract infection (UTI). She received antibiotics for the UTI. The review has determined 
that the items/services at issue in this case were not medically reasonable or 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 the PCR flu testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the influenza by PCR testing provided on January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on March 29, 2020, to April 1, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that your 
stay would either be $225 or $250. 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 $275 
copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for days 1-3 for an inpatient hospital stay. The total 
amount you are being asked to pay is $825 ($275 x 3 days = $825). An inpatient hospital stay falls within the 
inpatient hospital care 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 inpatient 
hospital stay provided by a participating provider on March 29, 2020, to April 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Evenity (romosozumab). 
 
You asked the Plan to pre-approve Evenity. You say that the enrollee is at a high risk of fracture and other 
bisphosphonates would not be appropriate. The Plan denied your request. The Plan says the denial of 
authorization for this drug is correct, because the records do not show that the enrollee has tried and failed 
bisphosphonate therapy or that the enrollee cannot take bisphosphonate drugs orally or in a vein. 
 
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 Evenity. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Evenity. Our physician reviewer found 
based on the medical records provided, there is no documentation that the Evenity is medically reasonable and 
necessary for the enrollee as there is no documentation that the enrollee has tried and failed (or has a 
contraindication to) bisphosphonate therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Evenity (romosozumab).
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires or can tolerate an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission for SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you have had multiple falls and you were 
previously discharged from the hospital and you went to a family member's home and they could not 
accommodate you. You say that you cannot physically move around and perform self-maintenance and you 
had to be readmitted. You say that you feel all of these circumstances should be considered. The Plan denied 
your request. The Plan says your clinical condition does not meet the CMS criteria for the SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that based on the 
documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required 
 
 
to establish a maintenance program or to prevent deterioration of your condition. 
 
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 pre-approve an admission for SNF services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is a continuation of therapy. The Plan denied your 
request. The Plan says osteopenia is not a medically accepted indication. 
 
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 Prolia. Our reviewer says that the 
submitted documentation does not support that Prolia is medically necessary. Our physician reviewer found no 
medical records have been submitted for review. The two prior authorization forms in the file provide 
contradictory information including different diagnoses, different prior therapies and different rationales for 
using the requested drug. Without medical records, it cannot be determined what information on the prior 
authorization forms is accurate. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo crowns.You asked the Plan to pre-approvethe crowns. You say that you did not get crowns before. You also say that you have not reached the maximum benefit.The Plan denied your request. The Plan says you have reached the maximum benefit of your Plan's policy.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 Plan offers a $2,500 annual dental benefit maximum for comprehensive services. The record shows that you werepre-approved for four retainer crowns and two pontics on August 18, 2020, totaling $2,500, and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvetwo crowns.
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 a stay in a rehab facility will benefit the 
enrollee. The Plan denied your request. The Plan says that there are no daily skilled nursing needs identified. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 25, 2019, by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that medical records prove medical necessity. The 
Plan denied your request. The Plan says a prior authorization was not obtained. 
 
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 April 25, 2019, by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on January 15, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the primary insurer is a different insurance plan. The claim has not been processed by the primary insurer. 
As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services rendered on January 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy. 
 
You asked the Plan to pre-approve additional physical therapy. The Plan denied your request. The Plan says 
additional therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional physical therapy. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has been receiving therapy and could 
further manage her condition with a home exercise program. Our reviewer says that the unique skills of a 
professional therapist are not required to safely and effectively provide ongoing treatment. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 16, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you faxed an authorization request to Optum and 
they responded that prior authorization was not required for this service. The Plan denied your request. The 
Plan says OON care is only covered by the plan in emergencies or urgent situation where a network provider is 
not available. No authorization was requested to treat the enrollee OON and there are network providers 
available. 
 
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 April 16, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent hospital care rendered on February 9, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not payable.The Plan must follow Medicare rules. The rules say that subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.We looked at the file and Medicare rules. The file shows that the Plan previously paid a claim for subsequent hospital services for the same date of service by the same provider. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care rendered on February 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the two removals of torus mandibularis (D7473 x2). 
 
You asked the Plan to pre-approve the removals of torus mandibularis. You say that you are unable to chew 
because you have no teeth. You also say that you do not have a job or money to pay for this. The Plan denied 
your request. The Plan says this service is not covered under your benefit package. 
 
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 the 
two removals of torus mandibularis (D7473 x2).