Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided from 4:40 pm on April 17, 
2020 through April 18, 2020. 
 
You asked the Plan to pay for post stabilization care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says inpatient care at an out-of-network facility was not 
medically necessary to stabilize the enrollee. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that post-stabilization care services at the out-of-network facility from 4:40 on April 17, 2020 through April 18, 
2020 were not medically necessary or reasonable. Our physician reviewer found the review indicates that by 
4:39 p.m. on April 17, 2020, the enrollee was stable for ambulance transportation with monitoring to a Plan 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post stabilization care provided from 4:40 pm April 17, 2020 through April 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 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 procedure code 87481 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 
 
We find that CPT code 87481 is not supported in the medical record. Specifically, there is no documentation of 
infectious agent detection of Candida species. 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 
laboratory services rendered on May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi for the enrollee. 
 
You asked the Plan to pre-approve Mvasi. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Mvasi. Our reviewer says that Mvasi is 
not medically reasonable and necessary for the enrollee in this case. Mvasi is to be given with Gemcitabine to 
treat pancreatic cancer previously treated with radiation and chemotherapy. The tumor has a genetic mutation 
suggesting possible response to Bevacizumab (Mvasi.). Mvasi is not FDA approved for pancreatic cancer. 
None of the CMS approved compendia support the requested use. There are no supporting citations in a 
PubMed search. The use of this medication is not listed as not indicated, not supported or not recommended in 
any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for Mvasi. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Mvasi for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says rules for 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found RFA of the SI joints is not the standard 
of care for low back pain or sacroilitis. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device with associated codes 
(E0650, E0673, E0666, 97760). 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says the enrollee does not have lymphedema or chronic insufficiency with 
venous stasis ulcers. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device 
with associated codes (E0650, E0673, E0666, 97760).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reinstatement of the 2020 vision benefits. 
 
You asked the Plan to pre-approve the reinstatement. You say that this is necessary due to diabetes. The Plan 
denied your request. The Plan says the 2020 vision benefit has been exhausted. 
 
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 these services with up to $250 benefit each year. 
 
 
 
 
 
 
 
 
 
We looked at the file and the Plan's rules. The file shows that the 2020 vision benefit was exhausted in March. 
The benefit cannot be reinstated. Based on this information, we decided that the Plan's rules for coverage of the 
reinstatement have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
reinstatement of the 2020 vision benefits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 
close supervision by a rehab doctor, or have complex rehab needs that can only be met at an IRF. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for coronary artery bypass grafting. Your medical problems are 
stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for 
physical and occupational therapy, but it does not support a need for an intensive rehab therapy program. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy services provided. 
 
You asked the Plan to pay for the infrared therapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is considered non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the infrared therapy services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth number 4 (D2752). 
 
You asked the Plan to pre-approve the crown. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this service is allowed one time every 60 months and 
the records show you had this service less than 60 months ago. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Specifically, the record indicates that you received this service on this 
tooth in 2018. This service is allowed once every 5 years and less than 5 years have passed. Therefore, we 
decided that the Plan does not have to pre-approve a crown on tooth number 4 (D2752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Lens, polycarbonate or equal, any index, per lens (V2784) 
provided on September 1, 2020. 
 
You asked the Plan to pay for routine vision hardware services. You say that you were unaware there was a 
maximum for this benefit. The Plan denied your request. The Plan says you were made aware of the maximum 
benefit allowable for routine vision hardware services prior to the service. 
 
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 allows up to $100 per calendar year for a combination of routine prescription contacts, 
routine prescription lenses, routine vision frames, and/or upgrades, such as tinting.  
 
We looked at the file and the Plan's rules. We have found that you have exceeded the maximum allowed for 
routine vision hardware. Based on this information, we decided that the Plan's rules for coverage of routine 
vision hardware services have not been met. Therefore, we decided that the Plan does not have to pay for Lens, 
polycarbonate or equal, any index, per lens (V2784) provided on September 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve Entresto. You say that the enrollee cannot tolerate an increase in beta 
blockers. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 
Medicare 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 Entresto.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from May 1, 2020 
through May 23, 2020. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you weren't informed about having 
to pay for part of it. You say that you can't afford the copayment. The Plan denied your request. The Plan says 
the copayment applied correctly. 
 
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 $0 
copayment each day for days 1 to 20 and a $160 copayment each day for days 21 to 62 at an in-network 
provider.  
 
You have been asked to pay $3,040 copayment for the SNF stay.  
 
Date of Service                           SNF Days      Number of Days      Copayment      Member Liability 
April 14, 2020-April 30, 2020        1-17              17                          $0/day             $0 
May 1, 2020- May 3, 2020           18-20            3                            $0/day             $0 
May 4, 2020- May 23, 2020         21-39            19                          $160/day          $3,040 
TOTAL:                                                                                                               $3,040 
  
The SNF stay falls within the "Skilled Nursing Facility (SNF) Care" benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the SNF stay provided from May 1, 2020 through May 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 19, 2020, to 
July 12, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from June 19, 2020, to July 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on June 5, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 5, 2020.
Appeal type: DME/ Orthotics
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 the PT/INR monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the requested equipment can be 
provided in-network. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing. 
 
You asked the Plan to pay for the screening testing. You say that you would like reconsideration because this 
testing was medically necessary. The Plan denied your request. The Plan says tests with no relation to a 
medical diagnosis of disease for the health of the patient are not a benefit. 

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the screening testing, was requested solely for screening purposes. Medicare 
does not cover routine screening and prophylactic testing for lipid disorder. Therefore, we decided that the Plan 
does not have to pay for molecular genetic hereditary predictive screening testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and two extractions to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the consultation and extractions. You say that you need 3 molars removed, 
and one has a hole and is hurting you. The Plan denied your request. The Plan says dental services are only 
covered when they are performed by a participating general dentist. The Plan also says that dental services 
performed by an oral surgeon are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation and two extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on June 3, 2020. 
 
You asked the Plan to pay for hearing aids. You say that the service was medically necessary. The Plan denied 
your request. The Plan says hearing aids ordered through providers other than the Plan?s hearing department 
are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when you contact and order through the Plan's hearing department. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of hearing aids have not been met. Specifically, you did not order your hearing 
aids through the Plan. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-Ray examination provided on July 6, 
2020. 
 
You asked the Plan to waive the copayment for X-Ray exam. You say that this test was ordered by your 
primary care doctor and should be paid. The Plan denied your request. The Plan says the copayment amount 
you are being charged is correct. 
 
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 $95 
copayment for in-network X-Ray exam at an outpatient hospital.  
 
You have been asked to pay the allowed amount of $71.90, which is less than the $95 copayment for X-Ray 
exam. X-Ray exam falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 X-Ray examination provided on July 6, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on May 8, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
diagnostic radiology services. 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 diagnostic radiology services provided on May 8, 
2020.