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

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you do not meet the Plan's criteria for the foot 
orthotics but believe you require them due to a medical condition you have had for most of your life. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on 
April 1, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the 
services were not authorized. Members must receive care from a network provider and in most cases, care 
received from an out-of-network provider will not be covered, except for the following: emergency care or 
urgently needed service and needed medical care that Medicare requires our plan to cover and the providers in 
our network cannot provide this care, which requires 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 
psychotherapy 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 psychotherapy services provided on April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided from February 
27, 2019 to September 24, 2019. 
 
You asked the Plan to pay for periodontal maintenance. You say that you should be reimbursed because you 
also had cleanings done. The Plan denied your request. The Plan says these 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, the requested items or services are not 
among those covered under this benefit. The submitted documentation does not show that you were charged for 
any preventative services. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910) provided from February 27, 2019 to September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 14, 2020 to 
March 31, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the service 
was 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 14, 2020 to March 31, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a breast MRI. 
 
You asked the Plan to pre-approve a breast MRI. You say that the requested breast MRI is medically necessary. 
The Plan denied your request. The Plan says that the requested breast MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 breast MRI. Our reviewer says that 
the requested breast MRI is medically necessary. Our physician reviewer found the enrollee is with a history of 
breast cancer. Per the American college radiology 2018-resolution 34, the requested MRI is medically 
necessary for high risk patients. As this enrollee has had breast cancer, she is high risk and the requested MRI 
is medically reasonable and necessary 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 a breast MRI have been met. Therefore, we decided that the Plan has to pre-
approve a breast MRI.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 10, 2020 
to January 20, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF coverage 
during the requested time frame does not meet the Medicare coverage guidelines. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 10, 2020 to January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 23, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 23, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you are receiving the appropriate care in the Inpatient Rehabilitation 
Facility. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CX Bladder test provided to the enrollee on April 29, 
2020. 
 
You asked the Plan to pay for this claim. You say that this test should be covered by the Plan. The Plan denied 
your request. The Plan says this test is not covered by Medicare or the Plan. 
 
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 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 CX Bladder test provided to the enrollee on April 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided on November 1, 2019 through 
November 30, 2019. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration because this claim 
has not been paid. The Plan denied your request. The Plan says this claim was submitted without a valid 
RUG/PDPM code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Specifically, this claim was not submitted with a valid Health 
Insurance Prospective Payment System code. Therefore, we decided that the Plan does not have to pay for SNF 
services provided on November 1, 2019 through November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frontal sinus balloon sinuplasty. 
 
You asked the Plan to pre-approve frontal sinus balloon sinuplasty. You say that the requested frontal sinus 
balloon sinuplasty is medically necessary. The Plan denied your request. The Plan says the requested frontal 
sinus balloon sinuplasty is not medically necessary. 
 
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 frontal sinus balloon sinuplasty. Our 
reviewer says that the requested frontal sinus balloon sinuplasty is not medically necessary. Our physician 
reviewer found according to the guidelines set by the American Academy of Otolaryngology for balloon 
sinuplasty, a frontal sinus balloon dilation is not indicated for a patient with nasal polyposis. The enrollee has 
had nasal polyps in the past. On his physical exam from 5/2020 he had nasal polyps on endoscopy. On his CT 
scan in 6/2020, he was noted to have nasal polyps. Therefore, the enrollee does not meet criteria for the 
procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of frontal sinus balloon sinuplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve frontal sinus balloon sinuplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on May 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the referring provider is out-of-network. The Plan says that the rendering facility is also out-of-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 anesthesia services provided on May 13, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup and bridge provided on April 4, 2020. 
 
You asked the Plan to pay for the core buildup and bridge. You say that the information indicated the enrollee 
had benefits for a bridge. You say that claim needs to be reprocessed according to the dental insurance 
coverage. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 core 
buildup and bridge provided on April 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 20, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges due to 
scheduling issues. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for advanced radiology services. 
 
The medical records show that you received an MRI on March 20, 2020. Therefore, you are responsible to pay 
the $150 copayment.  
 
You have been asked to pay a $150 copayment for an MRI. An MRI falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an MRI provided on March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on 
March 23, 2020. 
 
You asked the Plan to pay for the orthosis and sleeve. You say that this was medically necessary for the 
enrollee. The Plan denied your request. The Plan says that there is a non-valid physician order. 
 
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 pay for the orthosis and sleeve. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. There is 
no valid physician order and there is a lack of supporting information in the medical records for the codes 
billed. There are not any medical records from the prescribing physician within the last six months showing 
that the member had a face-to-face examination with the member. The member has not seen his primary care 
physician (PCP) for a while due to the distance and he does not have transportation. The member was not sure 
if his PCP prescribed the brace or not because he has not seen his doctor for a while. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these items. 
 
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 orthosis and sleeve have not been met. Therefore, we decided that the Plan 
does not have to pay for the knee orthosis and sleeve provided to the enrollee on March 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the two custom fabricated abutments and two abutment 
supported porcelain fused to metal crowns provided on January 30, 2020. 
 
You asked the Plan to pay more for the custom fabricated abutments and abutment supported porcelain fused to 
metal crowns. You say that these services were provided due to an accidental fall, and you would like this 
processed under your medical insurance. You also say that this claim was processed incorrectly as a dental 
claim, and you would like your file adjusted to show that the $200 is still available for dental benefits. The Plan 
denied your request. The Plan says these services are dental in nature. The Plan also says that the Plan has paid 
the annual limit allowed by your dental plan for this benefit year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers an allowance of $200 
every year for Non-Medicare covered preventive dental and Non-Medicare covered comprehensive dental 
services combined. The contract says that you are responsible for any amount above the dental coverage limit. 
The record shows that you met the annual allowance while processing this claim from January 30, 2020, and 
your annual allowance has been exhausted. Therefore, we decided that the Plan does not have to pay more for 
the two custom fabricated abutments and two abutment supported porcelain fused to metal crowns provided on 
January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT Scan of the brain (70450) provided on February 5, 
2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because this claim 
denied as a duplicate in error. The Plan denied your request. The Plan says the claim was denied correctly on 
the basis of diagnosis, modifier, provider tax ID, bill charge, date of service, patient name, units, billing 
provider address. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We find that CPT code 70450 is not supported in the record. Specifically, the records indicate that this service 
was rendered once and previously paid by the Plan. Based on this information, we decided that Medicare rules 
for coverage of the CT Scan have not been met. Therefore, we decided that the Plan does not have to pay for a 
CT Scan of the brain (70450) provided on February 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the documentation provided does not identify skilled nursing needs. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 17, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because this testing was not billed with the appropriate 
coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service March 17, 2020.  
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on March 17, 2020.