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

 
We decided that the Plan does not have to pay for the inpatient care provided to the enrollee from December 
14, 2019, to December 15, 2019. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer. 

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 the inpatient care. Our reviewer says that the 
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the 
enrollee was stabilized by December 14, 2019, and should have been considered for transfer to an approved 
facility.   Alternatively, approval could have been sought for ongoing inpatient care at the same hospital. A 
request for pre-approval was not initiated as required by the plan. Without the request or granted pre-approval, 
post stabilization care cannot be approved. The plan has approved inpatient care until 10:00am on December 
14, 2019. Further inpatient care is not supported. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided to the enrollee from December 14, 2019, to December 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on June 4, 2020.You asked the Plan to pay forthe dental services. You say that you only received these services once in the previous year. You also say that the services are within the limitations.The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says 1 panoramic x-ray is covered every 3 plan years. The Plan also says that the frequency limit for these services 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 and the services you received are listed, the frequency limit of once every 3 plan years has been exceeded. The record shows that you received these services on April 10, 2019.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on June 4, 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral formula provided from October 11, 2019 to 
November 8, 2019. 
 
You asked the Plan to pay for enteral formula (B4152). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says a valid physician order was not submitted. 
 
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 physician order for the supplies provided in this case. The physician order 
submitted is dated after the date of service. 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 enteral 
formula provided from October 11, 2019 to November 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information submitted does not meet the plan's medical necessity guidelines for 
coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary.  
 
 
Our physician reviewer found the plan requires a trial of Zoledronic acid or Pamidronate before they will 
approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no 
documentation provided indicating that the plan's required drug(s) likely be less effective and/or likely have 
adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Xgeva for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (72170) provided on June 15, 2020. 
 
You asked the Plan to pay for the radiology services (72170). 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72170 
has a bundled relationship with code 73502 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services (72170) provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 7, 2019 to 
December 31, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that it is difficult for the enrollee to be transported to 
the doctor's office. The Plan denied your request. The Plan says there is no network deficiency for the services, 
and alternate network providers were found. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on October 7, 2019 to December 31, 2019 by an 
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (back brace L0650) provided on 
February 22, 2020. 
 
You asked the Plan to pay for back brace. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because this item was ordered 
by telemedicine which is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(back brace L0650) provided on February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
hospital on May 26, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you shouldn't have to pay for something 
that caused radiation burn. 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 $130 
copayment for outpatient diagnostic tests/x-rays/other location.  
 
You have been asked to pay a $130 copayment for an x-ray. An x-ray falls within the outpatient diagnostic 
tests/x-rays/other location 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 
provided by a participating hospital on May 26, 2020.  
 
We note your complaint about getting burned from the x-ray. Your complaint is a grievance that must be 
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you cannot use your dentures. You say that 
your bottom denture does not fit. You say that you cannot eat. You also say that you cannot wait another 5 
years to get a new set of dentures. The Plan denied your request. The Plan says dentures are covered once every 
5 years. The Plan says that the frequency limit of once every 5 years has been reached. 
 
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 and dentures are a covered service, the 
frequency limit has been reached. The record shows that you received a complete set of dentures on September 
2, 2020. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) 
and a complete lower denture (D5120).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided from January 14, 
2020 to January 25, 2020. 
 
You asked the Plan to pay for the services. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says the enrollee's stay was custodial. 
 
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 looked at the file and Medicare rules. Based on the records provided the enrollee did not require daily 
skilled nursing services and was no longer benefiting from therapy after January 14, 2020. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility services provided from January 14, 2020 
to January 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on April 17, 2020. 
 
You asked the Plan to pay for the transportation services. You say that the enrollee was not yet on hospice at 
the time the services were rendered. 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. The Plan also says that 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.  
 
Although the enrollee was not under the Medicare hospice benefit at the exact time the services were rendered, 
the enrollee was under the Medicare hospice benefit on the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance transportation provided on April 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided on April 21, 2020, and April 22, 2020.You asked the Plan to pay forthe self-administered drugs. You say that these drugs should be covered under your Medicare Part D benefit.The Plan denied your request. The Plan says your medical benefit does not cover self-administered drugs.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 pay forthe self-administered drugsprovided on April 21, 2020, and April 22, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological examination services (CPT 74230) provided to 
the enrollee on June 9, 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 this is an exact duplicate to a previous claim. 
 
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 74230 is "Radiologic examination, gastrointestinal tract." 
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found a review 
of the records shows a single report for a video swallow on date of service 6/9/20. There is no report within the 
submitted records to justify a second charge. 
 
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 radiological examination services (CPT 74230) provided to the enrollee on June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee would be better served with her clinical complexities in an LTACH setting.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee is not stable for transfer and that she can stay in the hospital to finish her treatments.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the current acute care hospital with acute respiratory failure related to COVID-19 pneumonia. She was treated with mechanical ventilation support with oxygen and failed extubation trial. The course was complicated by UTI, bacteremia, and bacterial pneumonia which were treated. A trach was placed, but she was successfully weaned and is receiving high flow oxygen (6L F1O2 60%). A PEG was placed and she is tolerating tube feeds. The enrollee appears to be improving, but requires additional acute care services to further stabilize which is likely to take 24 days or less based on recent notes. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to a lower level of care may be considered soon with further improvement. 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee was advised that a plan 
representative and was advised that the claim should not have been denied. You also say that the item is 
covered under the enrollee's plan. The Plan denied your request. The Plan says partial dentures are covered 
once every 5 years. The Plan says that the frequency limit for a partial denture has been reached. 
 
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 and partial dentures are a covered 
service, the frequency limit of once every 5 years has been reached. The record shows that the enrollee received 
a partial upper denture on July 27, 2017, thus exhausting the denture benefit. Therefore, we decided that the 
Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density scan provided on May 11, 2020. 
 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says not enough 
information was received to review the claim. 
 
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 claim provided shows that the testing was provided with a diagnosis of screening for osteoporosis. The test 
at issue was requested for screening purposes. Medicare does not cover this testing for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the bone density scan provided on May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Radiologic examination, professional component, provided 
on May 22, 2020. 
 
You asked the Plan to pay for Radiologic examination, chest; single view (71045). You say that records 
support that this procedure was performed by your provider. The Plan denied your request. The Plan says the 
modifier indicating the service as separate/distinct was not appended. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, in this case, the billing of code 71045 was submitted inappropriately due to the bundled 
relationship of services within the specialty group and insufficient information to show it was a separate and 
distinct service. This claim cannot be paid as billed. Therefore, we decided that the Plan does not have to pay 
for Radiologic examination, professional component, provided on May 22, 2020.