Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 pre-approve admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a 
practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 7, 8, 9, and 10 and core 
buildups, including any pins when required (D2950) for tooth #'s 7, 8, 9, and 10. 
 
You asked the Plan to pre-approve the crowns and core buildups. You say that you had to get some work done 
on your front teeth. The Plan denied your request. The Plan says these services exceed the maximum count 
allowed per period. 
 
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, crown (D2750) and core buildup 
(D2950) are each limited to one procedure per tooth every five plan years. The record shows that you received 
crowns (D2750) and core buildups (D2950) on tooth #'s 7, 8, 9, and 10 on February 14, 2018, and your crown 
and core buildup benefits for tooth #'s 7, 8, 9, and 10 have been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve crowns (D2750) for tooth #'s 7, 8, 9, and 10 and core buildups, including any pins 
when required (D2950) for tooth #'s 7, 8, 9, and 10.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for Medicare Part B drugs and 
outpatient mental health provided on March 16, 2020. 
 
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan 
denied your request. The Plan says this cost share was applied based on the services provided and the Plan 
contract agreement. 
 
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 cost 
share for Medicare Part B drugs (20% coinsurance) and outpatient mental health visits ($40 per visit).  
 
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 cost share charged for Medicare Part B drugs and outpatient mental health provided 
on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refraction (92015) provided July 15, 2020. 
 
You asked the Plan to pay for the refraction services. You say that after having cataract surgery your doctor's 
office made follow up appointments to determine if you would need a different glasses prescription. The Plan 
denied your request. The Plan says this service exceeds the benefit maximum of once a year. 
 
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 when provided as a part of a routine vision once per calendar year. 
The records show that this service was already provided on February 22, 2020. 
 
We looked at the file and the Plan's rules. the plan covers refraction once per calendar year with a routine 
vision visit. Based on this information, we decided that the Plan's rules for coverage of the refraction services 
have not been met. Therefore, we decided that the Plan does not have to pay for eye refraction (92015) 
provided July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two removals of torus mandibularis (D7473 x2). 
 
You asked the Plan to pre-approve the removals of torus mandibularis. You say that this service should be 
covered because you do not have any teeth. You also say that you need the surgery first in order to receive 
dentures. The Plan denied your request. The Plan says this service is not covered under your benefit package. 
 
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. Therefore, we decided that the Plan does not have to pre-approve two 
removals of torus mandibularis (D7473 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first month's rental of a multi-positional patient transfer 
system provided on August 1, 2019. 
 
You asked the Plan to pay for the rental charge for the transfer system. You say that this equipment was 
medically necessary and should be covered. The Plan denied your request. The Plan says payment cannot be 
made since the enrollee was an inpatient in a hospital and a skill nursing facility (SNF) for the month of 
August. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made for equipment rental for 
months in which the enrollee is not residing in the home.  
 
In this case, the first month's rental payment was billed on August 1, 2019. However, the documentation shows 
that the enrollee has been admitted to an inpatient hospital stay as of July 29, 2019. She was discharged on 
August 12, 2019 to a SNF. The SNF stay extended at least until August 30, 2019. Since the enrollee was not 
residing in the home at any time during the month of August 2019, no payment can be made for equipment 
during this period. Therefore, we decided that the Plan does not have to pay for the first month's rental of a 
multi-positional patient transfer system provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory infectious agent detection services (CPT 87633) 
provided to the enrollee on April 8, 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 respiratory infectious agent detection is non-covered by Medicare, and excluded from coverage. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
 
 
found respiratory infectious agent detection, CPT code 87633 (12-25 targets) is non-covered by Medicare and 
excluded from coverage. Use is restricted to when more limited panels would not be medically appropriate (e.g. 
patient critically ill, etc.). The review has determined that the enrollee did not meet the criteria for this testing. 
 
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 pay for respiratory infectious agent detection services (CPT 87633) provided to the enrollee on April 8, 
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF 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 pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to SNF 
following a stroke. From a nursing perspective, the enrollee received oral medications. The enrollee had stable 
vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and 
occupational therapy in the SNF.  By the dates in question, the enrollee was at a minimal assist to contact guard 
assist level with functional mobility including gait to 150 feet with a rolling walker.  The enrollee required 
varying assist with activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis.  This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 17, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 17, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport 
provided on November 25, 2019. 
 
You asked the Plan to waive this copayment. You say that you would like this copayment waived. The Plan 
denied your request. The Plan says this copayment was charged based on the Plan contract. 
 
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 $225 
copayment for ambulance transport.  
 
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 $225 copayment charged for ambulance transport provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and core buildup, including any pins when 
required to be rendered by an OON provider. 
 
You asked the Plan to pre-approve the crown and core buildup. The Plan denied your request. The Plan says 
services provided by an OON or non-contracted provider are not covered under the enrollee's benefit program. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
crown and core buildup, including any pins when required to be rendered by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist/hand orthosis provided to the enrollee on April 15, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that this was medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of 
delivery submitted did not include any itemized shipping invoice to show what was sent to the enrollee. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the wrist/hand orthosis provided to the enrollee on 
April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on May 25, 2020, to July 25, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were not told 
that you would be charged monthly. The Plan denied your request. The Plan says the correct coinsurance has 
been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $8,776.80. The total amount you are being asked to pay is $1,755.36 ($8,776.80 x 20% 
= $1,755.36). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating 
provider on May 25, 2020, to July 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO) provided to the enrollee on 
December 23, 2019. 
 
You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not indicate the provider discussed the need for the billed 
supply code; therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of HCPCS code L0650 is "Lumbar-sacral orthosis, sagittal-
coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal 
junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary 
pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, 
pendulous abdomen design, prefabricated." 
 
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 orthosis. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the case 
file contains medical records dated 1/28/2020. There is no documentation of a physical examination of the 
back. The available documentation in the case file does not support that the requested lumbar-sacral orthosis 
was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria. An 
appropriate history and a physical examination of the back would reasonably be required to adequately assess 
whether the coverage criteria for an LSO have been met. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a lumbar-sacral orthosis (LSO) provided to the enrollee on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly/operation of a heart/lung machine provided on 
February 12, 2020 during an inpatient hospital stay. 
 
You asked the Plan to pay for the heart/lung machine services. You say that these services were medically 
necessary and require the services of a trained medical professional. The Plan denied your request. The Plan 
says no separate payment is made for this service when provided to a hospital inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
Although these services may be appropriate, payment for them is made to the hospital which must then furnish 
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for 
the services at issue. Therefore, we decided that the Plan does not have to pay for the assembly/operation of a 
heart/lung machine provided on February 12, 2020 during an inpatient hospital stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the requested CPT codes are not supported in the medical record. Specifically, the records do not 
show that the testing was performed with blood sampling. The records show that a urine specimen was 
collected. The billed services cannot be verified. 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 pay for the lab 
services provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental visit to be rendered by an OON provider. 
 
You asked the Plan to pre-approve the dental visit. You say that you would like to go to a dentist who can 
provide the services you need. The Plan denied your request. The Plan says your request is to be seen by an 
OON provider, but your needs can be met in-network. The Plan also says that there are 100 in-network 
providers within a 20-mile radius of your zip code. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
dental visit to be rendered by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you would like the requested power scooter to 
put in your car to use outside of the home and that you may use it in your home after your knee surgery 
scheduled in December 2020. The Plan denied your request. The Plan says you do not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, that your 
condition can be improved by a walker, cane or manual wheelchair, or if you can safely operate the PMD being 
requested. Furthermore, you are requesting the power scooter to be used outside of the home. Medicare will not 
pay for durable medical equipment that is needed for use outside the home. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter.