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

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three out of network consultations.  
 
You asked the Plan to pre-approve out of network visits. You say that you prefer to see the requested out of 
network provider. The Plan denied your request. The Plan says this treatment 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 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 three out of network 
consultations.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra Blue Test Strips. 
 
You asked the Plan to pre-approve OneTouch Ultra Blue Test Strips. You say that the patient is testing their 
blood glucose sugar levels four times per day, the patient needs to test more than three times per  day for labile 
glucose, the patient is not on an insulin pump, and the patient cannot use the preferred test strips because these 
test strips are used with their machine. The Plan denied your request. The Plan says their preferred strip is 
Accu-Chek. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
Based on this information, we decided that Medicare rules for coverage of OneTouch Ultra Blue Test Strips 
have not been met. We denied this request because Accu-Chek is the preferred brand of test strips in your plan. 
The Accu-Chek strips and reader work like the patient's current meter. If the patient is synchronizing their 
current meter with an insulin pump or another electronic device or have another reason to keep using it, please 
submit supporting information. Therefore, we decided that the Plan does not have to pre-approve OneTouch 
Ultra Blue Test Strips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (vitamin assay) provided to the enrollee on 
December 4, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this testing is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests are not covered. The rules say 
that preventative vitamin assays are not covered. Therefore, we decided that the Plan does not have to pay for 
lab services (vitamin assay) provided to the enrollee on December 4, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services (76641-LT and 76641-RT) provided 
on July 16, 2020. 
 
You asked the Plan to pay for CPT codes 76641-LT and 76641-RT. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must confirm that Medicare 
coverage criteria have been met.  
 
We looked at the file and Medicare rules. In this case, although two ultrasound reports were submitted for 
bilateral breast global screening ultrasound, the reports are identical with identical accession numbers, identical 
date and time of service, identical date and time of physician signature, and identical comparison to a June 26, 
2020 mammogram, not to another ultrasound on the same day. The Plan paid on August 5, 2020 for CPT code 
76641-50, for date of service July 16, 2020, under a different claim. Therefore, we decided that the Plan does 
not have to pay for the ultrasound services (76641-LT and 76641-RT) provided on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a retreatment of previous root canal therapy (D3347). 
 
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that you would like to 
save the few teeth you have, and do not want the teeth pulled. You also say that the best way to save your teeth 
is to do a retreatment. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
retreatment of previous root canal therapy (D3347).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an 
inpatient basis, at a SNF level of care during the period of care under review. Your function was at or near your 
prior level of function and you could be discharged to a lower level of care for further services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630). 
 
You asked the Plan to pre-approve the drugs or medicaments. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's health plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
drugs or medicaments dispensed in the office for home use (D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided on September 26, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit 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. 
 
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 rest home visit services provided on 
September 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on September 11, 
2020. 
 
You asked the Plan to waive the copayment for vision care. You say that you should owe a $0 copayment for a 
glaucoma screening. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct 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 Plan clearly says that you must pay a $30 
copayment for each eye exam to diagnose and treat diseases and conditions of the eye and a $0 copayment for 
glaucoma screenings for vision care.  
 
The medical records show that you received vision care to diagnose or treat a medical condition on September 
11, 2020. Therefore, you are responsible to pay the $30 copayment.  
 
You have been asked to pay a $30 copayment for vision care. Vision care falls within the vision 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 vision care provided on September 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Trabeculoplasty by laser surgery, one or 
more sessions (65855) provided August 21, 2020. 
 
You asked the Plan to waive the copayment for the laser surgery. You say that you feel that this is not correct 
because you had this procedure twice before and did not have to pay this amount. The Plan denied your 
request. The Plan says this claim was processed and the correct copayment was 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 $200 
copayment per visit for outpatient surgery or procedure at an ambulatory surgical center.  
 
You have been asked to pay $200 copayment for the laser surgery. The laser surgery falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 Trabeculoplasty by laser surgery, one or more 
sessions (65855) provided August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network physician services for the enrollee. 
 
You asked the Plan to pre-approve out of network physician services under the Medicare benefit. You say that 
this care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does 
not have out of network Medicare benefits. The Plan indicates the enrollee is dual eligible and these services 
may be covered under the Medicaid benefit. 
 
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 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 out-of-network physician 
services for the enrollee under the Medicare benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthoses provided on July 13, 2020 and July 
14, 2020. 
 
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says there are no claims from the referring physician within the last 6 
months prior to the date of the 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 Delivery Ticket 
does not have the tracking number on it and the Proof of Delivery does not have a description of the items 
delivered. Also one of the USPS Proof of Deliver has a ship date of July 15, 2020 and delivery date of July 18, 
2020, neither of which is submitted as the claim date. 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 orthoses provided on July 13, 2020 
and July 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the cost would be greater if I was 
transported to the hospital. 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 August 23, 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 August 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve the surgical placement of implant body. You say that this service is 
medically necessary. 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 Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve the massage therapy. The Plan denied your request. The Plan says massage 
therapy is not a covered benefit under Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for acute kidney failure, requiring hemodialysis, associated with hydronephrosis and a kidney 
stone. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the retainer crowns. You say that you desperately need this dental work, and 
are on disability. You also say that you never would have paid for the optional supplemental benefits if you had 
been told that bridgework was not covered. The Plan denied your request. The Plan says the maximum allowed 
for your quarterly maximum benefit has been met. 
 
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 Plan offers a $200.00 allowance for 
comprehensive dental services every quarter. The contract says that after Plan paid benefits for comprehensive 
dental services, you are responsible for the remaining costs. The record shows that you had $701.00 of the 
remaining quarterly dental allowance which was approved for two pontics and one retainer crown, and your 
quarterly maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve two retainer crowns (D6740 x2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating 
provider on July 25, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were told that you would not have a 
copayment for this. You say that you would not have gotten this tattoo if you knew it would be this expensive. 
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 $250 
copayment for outpatient diagnostic tests/in-network/diagnostic radiology other than CT scans.  
 
You have been asked to pay a $250 copayment for an MRI. The correct copayment has been applied to the 
MRI that was provided. An MRI falls within the outpatient diagnostic tests/in-network/diagnostic radiology 
other than CT scans 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 MRI provided by 
a participating provider on July 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 3, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician 
services provided on June 3, 2020.