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

 
We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after 
August 6, 2020. 
 
You asked the Plan to pre-approve continued SNF care. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for SNF service is correct. 
 
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 does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a Skilled Nursing Facility (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 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 after August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided on February 5, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a screening mammography. 
 
You asked the Plan to pre-approve the screening mammography. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says that this service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the screening mammography. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has a left axillary mass for which no identifiable cause was found on 
chest computed tomography. Breast malignancy is a common cause of otherwise an unexplained axillary mass.  
 
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 screening mammography have been met. Therefore, we decided that the 
Plan has to pre-approve a screening mammography.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from 
April 13, 2020 to April 16, 2020. 
 
You asked the Plan to waive the copay for the inpatient hospital services. You say that you should not be 
responsible for the copay. The Plan denied your request. The Plan says that the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copay per day, days 1-7 of inpatient hospital care.  
 
You have been asked to pay a $675 copay for the inpatient hospital services. The inpatient hospital services fall 
within the days 1-7 of inpatient hospital 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 copay for 
the inpatient hospital services provided from April 13, 2020 to April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve food thickener. 
 
You asked the Plan to pre-approve the food thickener. You say that this food thickener is necessary to allow the 
enrollee to swallow his food without aspiration. The Plan denied your request. The Plan says nutritional items 
maybe only be covered as supplies for use with a feeding tube. This enrollee does not have a feeding tube so 
the requested item cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that enteral nutrients can be covered as a supply for 
use with a feeding tube which is covered as a prosthetic. 
 
Food thickener that is for use with orally consumed nutrients does not meet the definition of supplies for use 
with a prosthetic. There is no other Medicare benefit which would provide coverage for this. Therefore, we 
decided that the Plan does not have to pre-approve food thickener.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on March 22, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you feel the services were urgent and emergent. The Plan denied your request. The Plan says this service is 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 pay for the first intraoral periapical x-ray provided on March 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3310) provided on March 9, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that you are on a fixed income. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the endodontic therapy (D3310) provided on March 9, 2020.  
 
Your complaint about your dissatisfaction with the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, apolipoprotein, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Durolane. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has pain related to osteoarthritis of the left knee, confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet 
criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next Test Strips. 
 
You asked the Plan to pre-approve Contour Next Test Strips. You say that you would like reconsideration 
because these test strips are medically necessary. The Plan denied your request. The Plan says there is no 
medical reason to use test strips or a glucometer that is not Plan approved. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
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 Contour Next Test Strips. Our reviewer 
says that the documentation does not show why you must use Contour Next Test Strips. Our physician 
reviewer found this brand is used along with some Medtronic insulin pumps, but you are not sing a pump. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Contour Next Test Strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Contour Next Test Strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visits (99214) and Bier block injections (64450) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve office visits and Bier block injections to be provided by an OON provider. 
You say that you want to continue seeing your current provider since they are familiar with your problem and 
are able to offer the best treatment for you. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99214) and Bier block injections (64450) to be provided by an out of network (OON) provider.
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 there are no complex medical or intensive rehab needs requiring supervision by a rehab
physician.
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 records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication
management, skin and oxygen care, and daily therapy can be provided at a SNF. A less intensive, longer
duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period. An
IRF intensity is not warranted.
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Buzzaround Ex Extreme 4-wheel Heavy Duty Long Range 
Travel Scooter (E1399) purchased April 2, 2019. 
 
You asked the Plan to pay for the scooter. You say that you are seeking assistance for reimbursement of 
durable medical equipment that was originally submitted in April of 2019 through August 2019. The Plan 
denied your request. The Plan says there is no CMS coding for this specific scooter and the records sent by 
your provider indicates the enrollee is mobile around the house with a cane/walker and is able to drive. 
 
The Plan must follow Medicare rules. Medicare rules say that this plan will generally cover your medical care 
as long as the care you receive is considered medically necessary and you receive your care from a provider 
who is eligible to provide services under Original Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pay for 
Buzzaround Ex Extreme 4-wheel Heavy Duty Long Range Travel Scooter (E1399) purchased April 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three resin-based composites provided on July 24, 2019 
by an OON provider. 
 
You asked the Plan to pay for the resin-based composites. You say that you were not aware that this provider 
was not in-network with your plan. The Plan denied your request. The Plan says these services were rendered 
by a non-contracted provider. The Plan also says that no benefits are available for procedures performed by 
OON providers or outside of the providers contracted 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, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the three 
resin-based composites provided on July 24, 2019 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prolonged evaluation and management service (99358) 
provided on October 13, 2019. 
 
You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
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 99358 is prolonged evaluation and management service 
before and/or after direct patient care; first hour. 
 
 
We asked our coder 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 prolonged evaluation and management service. Our 
reviewer says that CPT code 99358 does not meet criteria for billing or reimbursement consideration. Our 
reviewer found the evaluation and management report, documents that 35 minutes of non face to face time 
performing additional research, was performed, however, time is not documented for the Evaluation and 
Management portion of the encounter. Therefore, time of more than 70 minutes cannot be verified. 
Additionally, documentation does not specify that the additional time was spent other than on the floor/unit to 
verify CPT 99358. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the prolonged evaluation and management service have not been met. 
Therefore, we decided that the Plan does not have to pay for a prolonged evaluation and management service 
(99358) provided on October 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current 
level of care. 
 
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 documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. 
 
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-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 19, 2020. 
 
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says 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 did not pre-approve the 
laboratory testing. 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 laboratory testing provided on February 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee needs physical therapy to 
gain strength. The Plan denied your request. The Plan says the enrollee's functional abilities will not improve 
significantly with continued home health. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the 
enrollee's condition. She was noted to have had extensive prior home health services. It is unclear how much 
prior physical therapy she had. The documentation does not support that she has had a significant change in her 
functional status. There is no evidence of a fall history and she ambulates without an assistive device in the 
home, although she has a walker which she uses outside the home. The records do not indicate that she requires 
the unique skills of a professional therapist to safely and effectively provide treatment. The services do not 
need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The 
documentation does not reveal that she has had a significant functional change from her baseline. The 
requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 
current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.