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

 
We decided that the Plan does not have to pre-approve Methadone. 
 
You asked the Plan to pre-approve Methadone. You say that the medication is necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Methadone.  
 
Benefits for Methadone 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that the enrollee would greatly benefit from a bone 
stimulator. The Plan denied your request. The Plan says the records do not show x-rays separated by a 
minimum of 90 days. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
was diagnosed with non-union first metatarsal medial cuneiform and painful hardware. She underwent right 
foot hardware removal, revision of non-union 1st metatarsal mediocuneiform, fusion of the mediocuneiform 
and navicular joint, and utilization of bone graft on 9/3/20. Records indicated that she was improving in the 
post-operative period with progressive weight bearing recommended as of 10/21/20. The 10/21/20 x-rays 
demonstrated hardware to be in appropriate position, solid bone graft at this location, and no evident joint space 
at the first metatarsal medial cuneiform. Under consideration is a request for an ultrasonic osteogenesis 
stimulator. Medicare criteria have not been met. There is no documentation of radiographs separated by a 
minimum of 90 days with no clinically significant evidence of fracture healing between the two sets of 
radiographs. The enrollee is not 3 months status post fusion surgery with evidence of failed fusion. Therefore, 
this request for an ultrasonic osteogenesis stimulator was not medically reasonable and 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 the stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an osteogenesis stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 5, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
physician?s 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 physician's services provided on March 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
24, 2020, to January 31, 2020. 
 
You asked the Plan to pay for the SNF care. You say that the services were necessary. The Plan denied your 
request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
24, 2020, to January 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine 
(72131) and a magnetic resonance imaging (MRI) of the lumbar spine (72148). 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine and a MRI of the lumbar spine. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans and MRIs 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 a CT scan of the lumbar spine and a 
MRI of the lumbar spine. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that a CT scan or a MRI is 
medically reasonable and necessary. The available records do not document any plain x-ray results of the lower 
back or failure of physician-prescribed treatment for the enrollee's symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the lumbar spine and a MRI of the lumbar spine have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of 
the lumbar spine (72131) and a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the hip (73700). 
 
You asked the Plan to pre-approve a CT scan of the hip. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 a CT scan of the hip. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no report of a plain x-ray 
of the pelvis and left hip. Absent such an exam the medical necessity for CT is not established. In addition, if 
an orthopedic referral is considered and further study of the hip is desired a magnetic resonance imaging (MRI) 
could also be considered but after an orthopedic evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the hip have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the hip (73700).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the item is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria is 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 a power scooter. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found the documentation does reveal that you have 
a personal mobility deficit but it is not clear that it impairs participation in mobility-related activities of daily 
living (MRADLs) in the home. The documentation does not reveal why your mobility deficit is unable to be 
helped by a manual wheelchair. There is no objective gait or detailed neuromuscular exam including an 
evaluation of the upper extremities. The documentation is not clear that you can safely maneuver the power 
scooter in the home or that the requested power scooter will significantly improve activities of daily living 
(ADL) performance in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from April 1, 2020, through 
April 20, 2020. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that someone made an error and you do not owe 
$175. 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 $0 per day for days 
1-20 and a $175 copayment per day for days 21-100. 
 
You have been asked to pay a $175 copayment for the SNF stay.  
 
Date of Service SNF Days Number of Days Copayment Member Liability 
March 30, 2020- 
March 31, 2020 
1 & 2 2 $0/day $0 
April 1, 2020- April 
18, 2020 
3-20 18 $0/day $0 
April 19, 2020-April 
20, 2020 
21 1 $175/day $175 
TOTAL:    $175 
 
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 April 1, 2020, through April 20, 2020.
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 whether additional inpatient care beyond December 31, 2020 is medically necessary 
cannot be determined, as no medical records have been submitted beyond December 20, 2020. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an urgent care visit provided on July 10, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an urgent care visit. You say that you were directed to urgent care because your 
provider couldn't get you in sooner. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says that a referral is not on file from the member's primary care physician. 
 
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 an urgent care visit provided on July 10, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (D3320), core 
buildup (D2950), and a crown (D2740). 
 
You asked the Plan to pre-approve endodontic therapy, premolar tooth, core buildup, and a crown. You say that 
the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
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 
endodontic therapy, premolar tooth (D3320), core buildup (D2950), and a crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. 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 laboratory services are not supported in the medical record. Specifically, these services should 
be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this equipment was essential and 
there are no restrictions on diagnosis codes correlating with this equipment. The Plan denied your request. The 
Plan says the denial of payment for this device is correct, because this device is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 11, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you brought x-rays with you to the dentist office. 
You say that because you brought x-rays with you and the dentist wanted to take more, you should not be 
liable. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan 
says that the frequency limit has been exceeded. 
 
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 frequency limit of 1 limited oral 
evaluation per plan year has been exceeded. The record shows that the Plan paid for the limited oral evaluation 
that you received on May 13, 2020, thus exhausting the benefit. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation (D0140) provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by an 
out-of-network provider on June 9, 2020, to July 15, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not agree with 
this copayment. You say that you would like this processed as in-network. 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 $20 
copayment for outpatient diagnostic tests/out-of-network/physician.  
 
You have been asked to pay a $20 copayment for outpatient hospital services. The total amount you are being 
asked to pay is $40 ($20 x 2 visits = $40). The in-network and out-of-network copayment for these service is 
$20. Outpatient hospital services fall within the outpatient diagnostic tests/out-of-network/physician 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 outpatient hospital services provided by an out-
of-network provider on June 9, 2020, to July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on July 28, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 skilled nursing services provided on July 28, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic blood pressure monitor provided on July 20, 
2020. 
 
You asked the Plan to pay for the provided item. You say that without a blood pressure cuff you have no way 
to determine your blood pressure. The Plan denied your request. The Plan says a blood pressure monitor is not 
covered by Medicare or your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pay for the automatic blood pressure monitor provided on 
July 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on June 2, 
2020. 
 
You asked the Plan to pay for nursing facility care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 
 
 
 
 
 
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on June 2, 
2020.