Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air conditioner. 
 
You asked the Plan to pre-approve the air conditioner. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no qualifying medical diagnosis. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an air conditioner.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says the 
injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet injections are covered for the above indications. 
 
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 facet joint injections. Our reviewer says 
that the requested facet injections are not medically reasonable and necessary. Our physician reviewer found 
that there is no recent documentation of a physical exam/assessment of the lumbar spine, the last was 
November 2019. There is no documentation of at least 3 months of moderate to severe pain with functional 
impairment and documentation that the pain was inadequately responsive to conservative care such as, non-
steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and/or physical therapy (as tolerated). In addition, 
there is no current documentation of the amount of pain relief received from the two most recent facet 
injections. The requested facet injections are not medically reasonable or necessary according to the coverage 
criteria established in the above LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport provided on January 
9, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the transport. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the transportation service was not emergent and was not pre-authorized. There 
were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
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 the non-emergent ambulance transport provided on January 9, 2020 by an out of 
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you 
received from an out-of-network provider. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you were never told that this 
facility was out-of-network. The Plan denied your request. The Plan says you were charged this copayment 
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 $195 
copayment per day for skilled nursing facility services at an out-of-network facility for days 1-35.  
 
Records show that you were in this out-of-network SNF for 16 days. You have been asked to pay a $195 
copayment for each day, totaling $3120. 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. The Plan cannot be held responsible for this out-of-network provider?s failure to advise 
you about their out-of-network status. Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility (SNF) services you received from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
February 22, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 
(L0650) provided to the enrollee on February 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF 
admission 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled 
nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require 
skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) defined by codes 
A4595, A4245, L0650 and L1851 provided to the enrollee on March 26, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
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, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. 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 durable medical equipment (DME) defined by codes A4595, A4245, L0650 and L1851 provided to the enrollee on March 26, 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 you would like reconsideration because the IRF 
admission has been recommended by the member's physicians. The Plan denied your request. The Plan says 
IRF admission is not reasonable and necessary. 
 
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 member's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The 
member's medical status does not currently require intensive physician and nursing oversight only in an IRF. 
The therapy documentation does not support that he can tolerate and requires the intensity of an IRF 
rehabilitation program. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF 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 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 patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient'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-approveacute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, panoramic x-ray, 
maxillary partial denture, and extraction provided on May 5, 2020 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, maxillary partial denture, 
and extraction. You say that in April your tooth broke, and no dentist was open because of the virus. You also 
say that you later contacted customer service and were told they would pay $195.00 of your bill. The Plan 
denied your request. The Plan says your coverage only provides for these services when they are performed by 
a participating provider. 
 
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 
comprehensive oral evaluation, panoramic x-ray, maxillary partial denture, and extraction provided on May 5, 
2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided January 13, 
2020 to January 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 a $225 
per day copayment for days 1-5 of inpatient hospital care. 
 
You have been asked to pay a $225 per day copayment for 5 days of inpatient hospital care (a $1,125 total). 
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 inpatient hospital care provided January 13, 2020 to January 
20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care starting 
September 28, 2020. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time beyond the dates in question as they were not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care beyond the dates in question as they did not have any suicidal or homicidal 
thoughts, auditory or visual hallucinations or abnormal behaviors. The health plan's denial of continued 
inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health 
treatment beyond the dates in question as noted above as they were not a danger to himself or others and did 
not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place 
beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Our 
physician reviewer was unable to find an individualized treatment plan however the entire record is not present. 
It appears that the services were supervised and evaluated by a physician. Based upon review the records 
provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment 
beyond the date in question of September 28, 2020 forward and could have been treated in a lesser restrictive 
setting as they were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions 
and was not showing any behaviors or aggression being cooperative and compliant while not showing any 
acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care starting September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation, additional intraoral x-rays, 
bitewing x-ray and prefabricated post and core provided on October 24, 2019 and November 12, 2019. 
 
You asked the Plan to pay for the comprehensive oral evaluation, additional intraoral x-rays, bitewing x-ray 
and prefabricated post and core. You say that you thought you were going to a participating provider. You say 
that your appeal should be overturned. The Plan denied your request. The Plan says the endodontic therapy, 
fluoride application, periodontal maintenance and panoramic x-ray were approved at the in-network rate. The 
remaining services are not covered. 
 
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, you also have a maximum benefit of 
two oral evaluations per calendar year, one intraoral x-ray per calendar year and one bitewing x-ray per 
calendar year. You received an oral evaluation on June 10, 2019 and October 21, 2019, one intraoral x-ray on 
October 21, 2019 and one bitewing x-ray on June 10, 2019, which exhausted your benefits. The prefabricated 
post and core are not listed as a covered benefit. 
  
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation, additional 
intraoral x-rays, bitewing x-ray and prefabricated post and core provided on October 24, 2019 and November 
12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D6104 x 8), a bone replacement graft 
(D7953 x 8), guided tissue regeneration (D4266 x 8), and a consultation (D9310). 
 
You asked the Plan to pre-approve the dental services. You say that you are not able to eat and have lost almost 
30 pounds as a result. You say that your mouth is all torn up. You also say that you have no will to live in your 
current condition. The Plan denied your request. The Plan says a bone graft is not listed as a covered service. 
The Plan says a bone replacement graft is not listed as a covered service. The Plan says guided tissue 
regeneration is not listed as a covered service either. The Plan also says that any service not listed is considered 
not covered. 
 
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 dental services are not 
among those covered under this benefit. The Evidence of Coverage clearly states the services that are covered 
as well as services that are not listed are not covered. Therefore, we decided that the Plan does not have to pre-
approve a bone graft (D6104 x 8), a bone replacement graft (D7953 x 8), guided tissue regeneration (D4266 x 
8), and a consultation (D9310).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 14, 2020 by an out of network (OON)provider.You asked the Plan to pay forthe OON medical services. You say that the provider is a mobile x-ray unit that provides x-rays to skilled nursing homes and other care homes. You say that prior claims have always been paid by the Plan.The Plan denied your request. The Plan says there was no network deficiency and the services could have been supplied by an in-network provider.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 networkproviders 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 forthe medical services provided on March 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus surgery. 
 
You asked the Plan to pre-approve the surgery. You say that you would like reconsideration because this 
procedure is medically necessary. The Plan denied your request. The Plan says the member has not exhausted 
conservative treatments. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that an appropriate course of medical treatment has been 
tried and failed by the enrollee in this case. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sinus surgery.