Persius/hicric huggingface dataset:
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 December 6, 2019 to December 11, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not think that 
you should have been charged a $90 copayment and a $1,580 copayment for the same thing. 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 $395 
copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay a $395 copayment per day for days 1-4. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay is $1,580 ($395 x 4 days = 
$1,580). When admitted to the hospital from the emergency room, the emergency room copayment is waived 
but an inpatient copayment is applied; therefore, the correct copayment has been applied. An inpatient hospital 
stay falls within the inpatient hospital care/in-network 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 December 6, 2019 to 
December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine drug testing (UDT) rendered on December 18, 
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 were not medically necessary.r SNF care have 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a listed diagnosis of long 
term (current) use of opiate analgesic. Medicare rules state that, if a lab bills laboratory services to Medicare, 
there must be a signed order from the treating physician (or a progress note to support the intent to order) and 
documentation to support the medical necessity of the ordered services. In this case, the Physician 
Authorization Form is dated September 18, 2018. Apendix A - Toxicology Drug Testing is signed September 
27, 2018. A Requisition Form is dated December 18, 2019. A limited medical note in the case file is dated 
December 18, 2019. There is insufficient evidence that the UDT was tailored to the enrollee's medical 
condition. The documentation is insufficient to support that the UDS and UDT were medically reasonable and 
necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the urine drug testing (UDT) rendered on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower extremity brace addition provided on April 7, 2020. 
 
You asked the Plan to pay for prosthetic/orthotic item. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because the documentation 
submitted does not include valid proof of delivery for the item billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due for a claim. The information submitted by the provider must 
corroborate the medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery for the specific item billed on this claim. Namely, the shipping information submitted does not match 
the date of service billed or itemize the specific item billed on this claim, and the delivery ticket submitted does 
not include proof of delivery. The Plan requested this information, but it was not provided. Without this 
information, you have not furnished to the Plan sufficient information to justify payment of the claim as it has 
been billed. Based on this information, we decided that Medicare rules for coverage of prosthetic/orthotic item 
have not been met. Therefore, we decided that the Plan does not have to pay for a lower extremity brace 
addition provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were 
not urgent or emergent, and not prior authorized. 
 
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 wound care 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 January 14, 2020 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 medical services provided on January 24, 2020 by an out 
of network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 January 24, 2020 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Livalo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from March 11, 2020, to May 25, 2020.

You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered from 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from March 11, 2020, to May 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis 
(74178). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the listed diagnosis for this request was 
gastritis which is not an indication for a CT scan without more clear symptoms to justify the imaging. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve the continuous glucose monitor and supplies. You say that the records 
provided support the need for the requested items. The Plan denied your request. The Plan says a CGM and 
related supplies are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic continuous glucose monitors and related 
supplies are covered by Medicare when specific criteria have been met. 
 
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 continuous glucose monitor and 
supplies. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
information provided does not show that the enrollee is checking BGS and taking MDI for insulin. 
 
We looked at this physician's review, the file, and Medicare rules. We also contacted the Plan, who in turn 
contacted the appellant and confirmed that there were no additional records available to support the need for 
the requested CGM and supplies. Based on this information, we decided that Medicare rules for coverage of the 
continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, without spectral or color 
Doppler echocardiography (CPT Code 93307). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says that the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient is status post atrial fibrillation ablation and was referred for post atrial fibrillation 
(AF) ablation echocardiography. Echocardiogrpahy post AF ablation is indicated to assess return of atrial 
mechanical function, to reassess thrombotic risk and as a predictor of recurrent AF based on atrial remodeling 
criteria. This is a reasonable and medically necessary use of echocardiography . 
 
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 echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode 
recording, when performed, complete, without spectral or color Doppler echocardiography (CPT Code 93307).  
 
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 crowns (D2750) for tooth #'s 2, 19, and 30. 
 
You asked the Plan to pre-approve the crowns. You say that you fell and broke your tooth and crowns, and are 
in a lot of pain when you eat. The Plan denied your request. The Plan says there is no clinical documentation or 
radiographic evidence identifying acute infection, periapical infection, periodontal infection, or recurrent 
decay. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
crowns are not medically necessary. Our physician reviewer found the prognosis of tooth #2 is poor due to the 
inadequate bone support. Our reviewer also found that the documentation presented was inadequate to 
determine if the criteria for coverage for replacement crowns for tooth #'s 19 and 30 have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2750) for tooth #'s 2, 19, and 30.
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 based on the medical records provided 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 does require physical therapy and occupational therapy services 
but does not require an intensive inpatient rehabilitation therapy program. The enrollee does not appear to be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not medically necessary. 
 
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 PET scan. Our physician reviewer 
found the documentation indicates that PET scans were approved 12/14/18, 4/11/19, 6/27/19, 9/25/19 and 
recent PET scan was performed in April 2020. The review has determined that the member has an indication 
for which a PET Scan can be covered at this time. The requested PET Scan is medically necessary and 
reasonable for the enrollee at this time. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT Code 78815).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuplazid. 
 
You asked the Plan to pre-approve Nuplazid. You say that you have had approval for this drug for the past 
year. The Plan denied your request. The Plan says this medication does not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nuplazid.  
 
Benefits for Nuplazid may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory assist device (E0471 x10). 
 
You asked the Plan to pre-approve a respiratory assist device. You say that the items 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 beneficiaries covered for the first three months of 
an E0470 or an E0471 device must be re-evaluated to establish the medical necessity of continued coverage by 
Medicare beyond the first three months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a respiratory assist device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a respiratory assist device (E0471 x10).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation (D7953) 
for tooth #'s 21, 22, 23, 24, 25, 26, and 27. 
 
You asked the Plan to pre-approve the bone replacement grafts. You say that you need these procedures done 
because you were approved for dentures. You also say that you need these services before you can get the 
dentures. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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. The Plan covers the bone 
replacement grafts when the services are medically necessary and reasonable.  
 
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 bone replacement grafts. Our 
reviewer says that the bone replacement grafts are not medically necessary. Our physician reviewer found there 
is no indication that there will be implant placement in the area of the extractions.  
 
Our reviewer found that the ridge adjacent to the areas of the proposed extractions do not significantly differ in 
height as to where the teeth currently remain, which is an indication as to how the residual ridge might resorb 
following extraction. Our physician reviewer also found that, as there will not be implant placement in the 
areas of the tooth removal, and there is not a significant loss of bone in other adjacent areas where teeth had 
been removed, there is no clear indication for a need for the requested bone graft and no finding of medical 
necessity. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the bone replacement grafts have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bone replacement grafts for ridge preservation (D7953) for tooth #'s 21, 22, 
23, 24, 25, 26, and 27.