Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided from May 14, 2019 to February 4, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the coverage does not provide for services from a provider who has opted out of Medicare. 
 
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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services provided from May 14, 2019 to February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care can be safely provided in a less intensive setting, for example: a skilled nursing 
facility or home with home health care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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. The enrollee 
was admitted for hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve other accessories, side guards (K0108). 
 
You asked the Plan to pre-approve the side guards. You say that the chair you currently use has  a power assist 
system, fits in your home, permits you to function within your tight home living space and live independently. 
The Plan denied your request. The Plan says side guards do not serve a medical purpose and are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve other accessories, side guards (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the established patient outpatient office visit (99215) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you were not aware that the provide was out of 
network.  When you got to the facility they didn't take your ID card asked if you still had your insurance and 
proceeded to see you. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the established patient outpatient office visit (99215) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 2020. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on May 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the spinal facet joints, with 
imaging guidance (64633). 
 
You asked the Plan to pre-approve this service. You say that radiofrequency ablation is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the requested 
procedure. 
 
The Plan follows Medicare rules. Medicare rules say that only when dual medial branch blocks (MBB's) 
provide 80% relief of the primary or index pain, with ability to perform previously painful movements 
consistent with the expected physiological effects of the agents utilized, may radiofrequency (RF) medial 
branch neurotomy be considered. 
 
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 this service. Our reviewer says that the 
request for radiofrequency ablation is not medically necessary or reasonable. Our physician reviewer found that 
the enrollee has chronic neck pain. He has had two prior diagnostic injections. The documentation does not 
show 80% pain relief after each set of injections. Additionally, cooled radiofrequency ablation is considered to 
be experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation of the spinal facet joints, with imaging guidance (64633).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a non-Plan urologist. 
 
You asked the Plan to pre-approve these services. You say that you have kidney stones that need to be taken 
care of immediately. The Plan denied your request. The Plan says the services are available from Plan 
providers. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to a non-Plan urologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alert device/push button alert system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an alert device/push button alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair ramp (K0108) on provided to the enrollee on 
July 1, 2020. 
 
You asked the Plan to pay for the wheelchair ramp. You say that you require the equipment.  The Plan denied 
your request. The Plan says Medicare will not cover equipment that is primarily and customarily used for 
nonmedical purposes or for the patient's comfort or convenience. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for a wheelchair ramp (K0108) on provided to the enrollee on July 1, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 150 skin barrier wipes or swabs (A5120) for 90 days, 
150 adhesive remover wipes (A4456) for 90 days, and 24 ostomy deodorants (A4394) for 90 days. 
 
You asked the Plan to pre-approve ostomy supplies. You say that these supplies are medically necessary. 
 The Plan denied your request. The Plan says these supplies exceed the maximum allowed amounts. 
 
The Plan follows Medicare rules. Medicare rules say that the explanation for use of a greater quantity of 
supplies than the amounts listed must be clearly documented in the beneficiary?s medical record. If adequate 
documentation is not provided when requested, the excess quantities will be denied as not 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 ostomy supplies. Our reviewer says that 
the criteria for coverage of the requested supplies has not been met. Our physician reviewer found the medical 
records did not provide a reason as to why the extra medical supplies are needed. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ostomy supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 150 skin barrier wipes or swabs (A5120) for 90 days, 150 adhesive remover wipes 
(A4456) for 90 days, and 24 ostomy deodorants (A4394) for 90 days.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 hours per week of home health aide services 
(G0156). 
 
You asked the Plan to pre-approve home health aide services. You say that home health aide services are 
medically necessary. The Plan denied your request. The Plan says rules for home health aide services have not 
been met. 
 
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 aide services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the medical records 
provided do not support the designated time period requested of home health aide 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 14 hours per week of home health aide services (G0156).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Foresee Home device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found home monitoring of your macular degeneration with Foresee Home is not medically necessary in this 
case. You are already receiving regular in-office monitoring and treatment for active macular degeneration, and 
there is no good argument that additional home monitoring would be warranted. The device is not the standard 
of care for treatment or monitoring of your diagnosis. The standard of care is home self-monitoring with 
Amsler grid. The Foresee Home system may be more effective than Amsler grid, but only a single study of 
relatively short duration (1.4 years of mean follow-up) exists to compare the efficacy. There is no evidence that 
the Foresee Home system improves disease outcomes, or that it would be superior for treatment of your disease 
as compared with standard treatments. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Foresee Home device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950) and pontic-porcelain fused to 
high noble metal (D6240). 
 
You asked the Plan to pre-approve the core buildup and pontic-porcelain fused to high noble. You say that the 
services requested are medically necessary. The Plan denied your request. The Plan says these services are not 
listed on the benefit chart and therefore not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup (D2950) and pontic-porcelain fused to high noble metal (D6240).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional three (3) PT visits. 
 
You asked the Plan to pre-approve an additional three (3) PT visits. The Plan denied your request. The Plan 
says the expectation does not exist that ongoing PT will result in the practical improvement in the enrollee's 
level of function within a defined period of time. 
 
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 an additional three (3) PT visits.. Our 
reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is 
not generally accepted as specific and effective therapy for your condition. You have had prior therapy for this 
condition and it does not appear that your functional level requires the unique skills of a professional therapist 
to safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. You have been educated in an independent exercise program. 
The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain your current condition or to prevent or slow further 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 an additional three (3) PT visits. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional three (3) PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided by a participating 
provider on July 7, 2020, to September 29, 2020. 
 
You asked the Plan to waive the copayment for injections. You say that since this was cancer related this 
should be covered. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for injections. The total allowed amount 
is $1,660.80. The total amount you are being asked to pay is $332.16 ($1,660.80 x 20% = $332.16). The correct 
coinsurance has been applied to the injections that were provided. Injections fall within the Medicare Part B 
prescription drugs 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 injections provided 
by a participating provider on July 7, 2020, to September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional test strips. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the documentation 
does not show why the allowed amount is not enough to manage blood sugars. 
 
The Plan follows Medicare rules. Medicare rules say that the quantity of tests strips are determined by certain medical 
indications. 
 
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 requested items. Our physician reviewer found that you are 
not on insulin. There is no documentation of labile diabetes with excessive hyper or hypo glycemia. There is no 
documentation or medical justification for the need of more than 5 test strips daily.  Therefore, the requested amount of 
test strips is 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 requested items have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment (D6057) and abutment supported 
porcelain/ceramic crown (D6058) provided August 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that you don't understand the difference in just 
having a crown and having a crown put on after an implant. This was a very expensive service and would like 
help for the crown. The Plan denied your request. The Plan says these services are not covered under the plan 
benefits. 
 
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 custom 
fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided August 19, 
2020.