Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a capsule endoscopy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is evidence of a pacemaker, making the procedure inadvisable. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the presence of a pacemaker is a theoretical and relative contraindication, but not an absolute 
contraindication, to the capsule endoscopy service under review. The enrollee has GI hemorrhage with iron 
deficiency anemia and thus meets provided coverage criteria for wireless capsule endoscopy. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a capsule endoscopy for the enrollee.  
 
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 pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like to go to this facility. 
The Plan denied your request. The Plan says that the request for an inpatient admission does not meet criteria 
and has been deemed medically appropriate for observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that acute inpatient hospital care is medically reasonable and 
necessary in this case. There is no specific clinical rationale for the requested inpatient admission after the 
elective procedure. The record does not show that at the time of inpatient admission the admitting physician 
reasonably expects that your necessary hospital care would span two midnights. Our physician reviewer found 
that your condition does not meet Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent skilled nursing facility care provided to the 
enrollee on June 10, 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 this is not a covered benefit with this provider. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the services. 
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 subsequent skilled nursing facility care provided to the enrollee on June 10, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a preventative dental service (D1999). 
 
You asked the Plan to pre-approve a preventative dental service. You say that the services are necessary. The 
Plan denied your request. The Plan says the requested 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 a 
preventative dental service (D1999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital physician services provided from January 
18, 2019, to January 19, 2019. 
 
You asked the Plan to pay for physician services. You say that according to your records this claim was 
submitted correctly and was not a duplicate claim. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because this claim was not submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for physician services was not filed until March 17, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for inpatient hospital physician services provided from January 18, 2019, to 
January 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services with the requested provider. 
 
You asked the Plan to pre-approve the mental health services. You say that you have worked with this provider 
for two years and he is the first counselor who has not wanted to just put you on medication. You say that 
previously you were seeing an in-network counselor who was abusive, so to find someone who is kind like this 
provider is not an easy thing to do and you are hesitant to find another counselor because good ones are hard to 
find. The Plan denied your request. The Plan says with limited exceptions, while you are a member of our plan 
you must use network providers to get your medical care and services. The only exceptions are emergencies, 
urgently needed services when the network is not available (generally, when you are out of the area), out-of-
area dialysis services, and cases in which the Plan authorizes use of out-of-network 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve mental 
health services to be provided by the requested provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hyaluronan injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed two cortisone 
injections. The Plan denied your request. The Plan says the documentation does not show that the enrollee has 
tried and failed conservative therapy. 
 
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 the requested services. Our physician 
reviewer found that an imaging report shows bone-on-bone arthritis in the medial compartment, and grade 2-3 
changes in patellofemoral compartment. The enrollee received a cortisone injection, which was ineffective.  
The enrollee also tried meloxicam which was ineffective. The enrollee received a steroid injection, however, 
medical records were not provided to document the effectiveness of the injection. Conservative therapy, such 
as physical therapy, was not documented in the medical records. The documentation does not support that the 
requested drug is medically reasonable and necessary for the 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Hyaluronan injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation. 
 
You asked the Plan to pre-approve deep sedation. You say that you have high anxiety levels and major cardiac 
issues. You say that you need to be under heavy sedation to have a tooth removed. 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 deep 
sedation.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 18, 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 on June 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide for bathing. 
 
You asked the Plan to pre-approve the services. You say that you had fallen and broken your arm recently. You 
state you can no longer help yourself up from your wheelchair, walk to the bathroom, or use the walker. The 
Plan denied your request. The Plan says the records indicate that you are not receiving skilled nursing services 
at home. 
 
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 the services. Our physician reviewer 
found based on the documentation provided, the health plan's denial should be upheld. In-home skilled nursing 
services have not been requested and are not shown to be medically necessary. In-home skilled therapy services 
have not been requested and are not shown to be medically necessary. In the absence of in-home skilled 
nursing or skilled therapy needs, home health aide services are not covered. 
 
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. Therefore, we decided that the Plan does not 
have to pre-approve home health aide for bathing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Zoster (shingles) vaccine and administration provided on January 24, 2020 and May 22, 2020.You asked the Plan to pay forthe Zoster (shingles) vaccine and administration. You say that you did not know it was not covered.The Plan denied your request. The Plan says the Zoster (shingles) vaccine and administration are not covered under your Medicare Part Bbenefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles) vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Zoster (shingles) vaccine and administration.Therefore, we decided that the Plan does not have to pay forthe Zoster (shingles) vaccine and administration provided on January 24, 2020 and May 22, 2020.Benefits for the Zoster (shingles) vaccine and administrationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one. 
 
You asked the Plan to pre-approve Gel-one. 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. 
 
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 Gel-one. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee was reported to have tried 
Orthovisc injections in the past to the right knee with "good relief." However, there was no report of the 
enrollee having failed either Monovisc or Orthovisc in any way. Repeat use of Orthovisc or Monovisc would 
not likely be less effective or cause adverse effects for the enrollee. Current literature suggests all 
viscosupplementation injection brands appear to have essentially equal effectiveness and safety. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair and a shower chair. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this request appears to exceed your medical needs. Your surgery was cancelled. There is no evidence that 
you are unable to ambulate currently or perform MRADLs without a wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a standard wheelchair and a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 16, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 July 16, 2020, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit (99204) with an out-of-network provider.You asked the Plan to pre-approvethe office visit. You say that the out-of-network consultation is medically necessary.The Plan denied your request. The Plan says 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 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 services at issue in thisappeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvean office visit (99204) with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug test (G0483) and presumptive drug test 
(80307) provided by an out of network (OON) provider. 
 
You asked the Plan to pay for drug tests. You say that the services provided 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 for the definitive drug test (G0483) and presumptive 
drug test (80307) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the skilled nursing facility (SNF) care 
provided from May 8, 2020, through June 1, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 for each admission 
enrollees pay $20 per day, for days 1-20 of a benefit period and $100 per day, for days 21-44 of a benefit 
period. Additionally, enrollees pay $0 per day, for days 45-100 of a benefit period. 
 
You have been asked to pay $800 ($20 x 20 days=$400+$100 x 4 days) for the skilled nursing facility care 
provided. 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 adjust the copayment for the skilled nursing facility (SNF) care provided 
from May 8, 2020, through June 1, 2020.  

Your complaint that you were advised by an employee at the provider's office that if you finished your 
rehabilitation and stayed another few days you would not be charged an additional copayment, is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forroutine eyewear provided on June 16, 2020.You asked the Plan to pay foreyewear. You say that you have no record of claiming benefits for this eyewear.The Plan denied your request. The Plan says the denial of payment for these items is correct, because the Plan has already paid the full $125 allowance for routine eyewear.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 routine eyewear up to $125 combined allowance for eyeglasses or contact lenses every 24 months.We looked at the file and the Plan's rules. The Plan has paid the full$125 allowance for eyewear; therefore, this benefit is exhausted. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met.Therefore, we decided that the Plan does not have to pay forroutine eyewear provided on June 16, 2020.