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

We decided that the Plan does not have to pay for ultrasound therapy (97035) provided by a chiropractor on
December 30, 2019.
You asked the Plan to pay for ultrasound therapy. You say that this service cost less from your chiropractor
than a physical therapist. The Plan denied your request. The Plan says this service is not covered when
provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for ultrasound therapy (97035) provided by a chiropractor on December 30,
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan for the enrollee.
You asked the Plan to pre-approve Hyalgan. The Plan denied your request. The Plan says that they did not
receive documentation supporting the medical necessity for a step therapy exception.
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 Hyalgan. Our reviewer says that
Hyalgan is not medically reasonable and necessary for the enrollee in this case. The documentation does not
support that the enrollee has tried and failed Monovisc and Orthovisc (Hyaluronic acid) or that they would
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician
reviewer found that the enrollee's condition does not meet step therapy criteria for Hyalgan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have
to pre-approve Hyalgan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve office visit. You say that your doctor has told you that there is nothing more
he can do for you, and you need to find a provider who can treat you. The Plan denied your request. The Plan
says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan
and you can be treated by an in-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 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 medical services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional occupational therapy home health visits (for
a total of 9).
You asked the Plan to pre-approve additional occupational therapy home health visits. You say that you would
like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are
not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 occupational therapy home
health visits. Our reviewer says that the documentation does not support that the requested home health
services are medically reasonable or necessary. Our physician reviewer found you required
supervision/independent for laundry, washing, and drying. The documentation does not include an indication
for skilled therapies for the goals outlines in the therapy notes. The documentation does not support that there
are any issues with skin care, medication management or IV medications.
The documentation does not support that you require the skilled therapists intervention beyond the number of
visits approved by the plan.
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 occupational therapy home health visits have not been met.
Therefore, we decided that the Plan does not have to pre-approve 5 additional occupational therapy home
health visits (for a total of 9).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from
September 12, 2019 through September 24, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary for the
enrollee. The Plan denied your request. The Plan says that that services could have been rendered at lower level
of care.
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 supports that the criteria for inpatient payment are met in this case. The record
showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's
necessary hospital care (including earlier emergency department and/or observation care) would span two
midnights. Our physician reviewer found that the enrollee's condition met 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided to the enrollee from September 12, 2019 through
September 24, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable X-ray services (73120, Q0092, R0070) provided
on January 21, 2020.
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the services were not preauthorized or emergent. The enrollee has
no out-of-network benefits.
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 portable X-ray services (73120, Q0092, R0070) provided on January 21,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for special endodontic therapy (D3310), crown (D2740) and
core build-up with pins (D2950) provided on November 21, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were hit in the face with a bungee cord that
broke your tooth. The Plan denied your request. The Plan says your request is not medically necessary because
the service is not covered under Medicare and the EOC does not provide a benefit for these services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for special endodontic therapy
(D3310), crown (D2740) and core build-up with pins (D2950) provided on November 21, 2019 by an out-ofnetwork
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the brand specific transcutaneous electrical nerve
stimulation device.
You asked the Plan to pre-approve brand specific transcutaneous electrical nerve stimulation (TENS) device.
You say that regular TENS devices do not work for you. The Plan denied your request. The Plan says there is
not enough peer reviewed data on this brand specific TENS unit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or
to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory
and regulatory requirements.
We looked at the file and Medicare rules. Medicare does not cover this brand of TENS device. Based on this
information, we decided that Medicare rules for coverage of the brand specific transcutaneous electrical nerve
stimulation (TENS) device have not been met. Therefore, we decided that the Plan does not have to preapprove
the brand specific transcutaneous electrical nerve stimulation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement portable oxygen concentrator with type H
cylinder.
You asked the Plan to pre-approve a replacement portable oxygen concentrator with type H cylinder. You say
that the enrollee needs this because there is a problem with consistent electric power supply. The Plan denied
your request. The Plan says that the equipment is requested as a safety or precautionary measure and not as
therapeutic treatment.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has a home based oxygen system and a portable oxygen concentrator. A home
based oxygen system and a portable oxygen concentrator serves the same purpose as a replacement portable
oxygen concentrator with type H cylinder. Therefore, we decided that the Plan does not have to pre-approve a
replacement portable oxygen concentrator with type H cylinder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-preferred brand of test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee is used to the
requested brand. The Plan denied your request. The Plan says there is no medical reason documented that the
enrollee is medically unable to use the Plan preferred test strips.
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 non-preferred brand of test strips.
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case.
Our physician reviewer found based on the medical records provided the enrollee does not meet the
requirement for non-preferred brand glucose test strips. The Plan offers multiple options for glucose monitors
and test strips on their preferred list. No medical reason is presented that one of the options from the preferred
list would not work 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 non-preferred brand of test strips have not been met. Therefore, we decided
that the Plan does not have to pre-approve the non-preferred brand of test strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery.
You asked the Plan to pre-approve spine surgery. 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. 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 spine surgery. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the medical records do not show evidence of spinal instability, fracture or lesion. There is no
clearly documented progressive myelopathy present. Criteria for surgery is not met. There is no documentation
of adequate physical therapy trial.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve spine surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on
November 25, 2019 and January 20, 2020.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you were billed incorrectly.
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 2019 Plan clearly says that you must pay
15% coinsurance for Part B drugs that are administered by a provider. Your contract with the 2020 Plan clearly
says you must pay 20% coinsurance for Part B drugs that are administered by a provider.
You have been asked to pay a total of $929.07 for the Part B injections. The Part B 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 coinsurance for the Part B injections provided by on November 25, 2019
and January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on February 6,
2020.
You asked the Plan to pay for a chiropractic office visit. You say that you were told chiropractic services would
be covered. The Plan denied your request. The Plan says this is not a covered chiropractic service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for a chiropractic office visit (99202) provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 9 additional extractions provided on May 21, 2019.
You asked the Plan to pay for the extractions. You say that a Plan representative told you that dentures would
be covered under your dental insurance. The Plan denied your request. The Plan says your extractions benefit
had been exhausted because two extractions were approved.
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, extractions are limited to two
procedures per calendar year. The record shows that you received 3 extractions on May 21, 2019, two were
covered, and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to
pay for the 9 additional extractions provided on May 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and extraction provided on December
10, 2019.
You asked the Plan to pay for the panoramic x-ray and extraction. You say that you, your dental office, and the
Plan believed you were covered for the services rendered on this date. The Plan denied your request. The Plan
says these services were provided by a dentist who has opted out of Medicare. The Plan also says that this
provider opted out of Medicare on December 18, 2015.
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. This
provider has opted out of the Medicare program. The file shows that the provider entered into a private contract
with you regarding payment. The records also confirm that there were no records of any customer service agent
quotes given to you or the dental office regarding your benefits or coverage. Therefore, we decided that the
Plan does not have to pay for the panoramic x-ray and extraction provided on December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET/CT scan skull base to mid thigh for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical information provided does not meet the criteria.
The Plan must follow Medicare rules. Medicare rules say that PET 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 the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found review of the current
NCCN guidelines indicates that in Merkel Cell Cancer advanced imaging after 3 years is indicated when there
is a high degree of clinical recurrence or metastasis. This is not the case in this enrollee who has no clinical
evidence of tumor recurrence, especially local. Also, importantly as was noted in the original records at the
time of surgical diagnosis Onco protein analysis was done but apparently has not been done in surveillance.
The NCCN guidelines indicate that if there is elevation of the MCPyV oncoprotein the possibility of tumor
recurrence is suspicious and aggressive monitoring is then indicated. This marker has not been done to and the
enrollee shows no clinical evidence of tumor. She is 3.5 years post diagnosis and has had 6 serial negative
PET/CT scans at 6 month intervals. For these reasons the medical necessity of PET/CT at this point have not
been established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve PET/CT scan skull base to mid thigh 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 December 10, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for office visit and laboratory test. You say that you were seen by a doctor who you
were told was part of the Plan and were not told that this visit would not be covered. The Plan denied your
request. The Plan says the denial of payment for these services is correct.
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 December 10,
2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder surgery to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve shoulder surgery. You say that you would like approval for these services
by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers
available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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
shoulder surgery to be provided by an out of network (OON) provider.