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

 
We decided that the Plan does not have to waive the coinsurance for an echocardiography procedure performed 
on July 6, 2020. 
 
You asked the Plan to waive the coinsurance for an echocardiography procedure. You say that your doctor 
ordered this procedure and that your doctor is in your network. The Plan denied your request. The Plan says the 
correct coinsurance 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 20% 
coinsurance for Medicare-covered diagnostic procedures and tests.  
 
You have been asked to pay $113.56, or 20% of the Medicare-allowed amount of $567.79, for an 
echocardiography procedure. An echocardiography procedure 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 coinsurance for 
an echocardiography procedure performed on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services you provided on June 25, 2019. Records 
show that you are an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
You are not a network provider with the Plan. 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 medical services you provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 10, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you feel the visit should be 
included as part of your colonoscopy screening. 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 $20 
copayment for specialist visits.  
 
You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s office visits 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 a specialist visit provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on 
June 1, 2020. 
 
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you bought the oxygen 
device to improve your ability to get around. The Plan denied your request. The Plan says only rented oxygen 
equipment is eligible for coverage. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home.  
 
We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. 
Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen 
concentrator purchased on June 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care from December 22, 2020, forward. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found as of December 22, 2020, the member did not 
require any skilled nursing or rehab services on a daily basis. The member was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or ADLs. The member did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the member did not require any skilled services on an 
inpatient basis, at a SNF level of care during the period of care under review. The member did not have any 
parental medications, complex wound care or nutrition given via a feeding tube.  The member received skilled 
care and improved, however their function had plateaued they did not require any further inpatient skilled rehab 
 
 
services. The members function was at or near their prior level of function and they could be discharged to a 
lower level of care for further services. As of December 22, 2020, the member required custodial services. The 
denial for further inpatient skilled care is upheld. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care from December 22, 2020, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (CPT Code 87633) provided. 
 
You asked the Plan to pay for the service. You say that this is a covered benefit. The Plan denied your request. 
The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Respiratory virus laboratory 
detection (eg. adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory 
syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified 
probe technique, multiple types or subtypes; is not covered. CPT 87633 (12-25 targets) is used when more 
limited panels would not be medically appropriate (e.g., patient critically ill, etc.). Use is restricted to when 
more limited panels would not be medically appropriate (e.g. patient critically ill, etc.) This is not a COVID-19 
 
 
test. This is not an emergency test. We must follow Medicare guidelines. Respiratory infectious agent 
detection, CPT code 87633 (12-25targets) is non-covered by Medicare and excluded from coverage. Use is 
restricted to when more limited panels would not be medically appropriate (e.g. patient critically ill, etc.) 
Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (CPT Code 87633) provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred 
drugs, or any reason why the plan preferred drugs would be unsafe or ineffective for this 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs are 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital, the 
member had stabilized medically.  The member did not require any skilled nursing or rehab services on a daily 
basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily 
living. The member did not require skilled therapy to establish a safe and effective maintenance program.  As a 
practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at 
 
 
the time of discharge from the hospital. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown-porcelain-ceramic (D2740 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says this service is not covered under the benefit 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. Specifically, crowns are not listed as a covered benefit in the Plan?s 
EOC. Therefore, we decided that the Plan does not have to pre-approve a crown-porcelain-ceramic (D2740
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT Code(s) 22869 
and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and 
efficacy. 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 pre-approve the Superion interspinous spacer (CPT Code(s) 22869 and 22870).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil. 
 
You asked the Plan to pre-approve Modafinil. You say that this is a continuation of therapy. The Plan denied 
your request. The Plan says this drug is not covered for the enrollee's condition by Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Modafinil.  
 
Benefits for Modafinil may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant (D6010), second stage implant surgery 
(D6011), a custom fabricated abutment (D6057), and an abutment supported crown (D6058). 
 
You asked the Plan to pre-approve an implant, implant surgery, a custom fabricated abutment and abutment 
supported crown. You say that the enrollee has multiple teeth that show signs of fracture and faulty 
restorations. You say that this results in pain for the enrollee. The Plan denied your request. The Plan says 
implant 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. Therefore, we decided that the Plan does not have to pre-approve an 
implant (D6010), second stage implant surgery (D6011), a custom fabricated abutment (D6057), and an 
abutment supported crown (D6058).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intrauterine device (IUD). 
 
You asked the Plan to pre-approve these services. You say that the IUD is only good for 10 years and you need 
to have it removed and replaced. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers specific preventive services only.  
 
We looked at the file and Medicare rules. The services at issue are an IUD for contraceptive purposes. This is a 
preventive service that is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve an intrauterine device (IUD).  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a pneumatic compression device (E0652). 
 
You asked the Plan to provide a pneumatic compression device. You say that a basic pump would result in 
increased truncal edema and pain. The Plan denied your request. The Plan says the enrollee has not had a 4 
week trial of a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
 
 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device 
(E0652).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT Code(s) 22869 
and 22870). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed. 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 pre-approve the Superion interspinous 
spacer (CPT Code(s) 22869 and 22870).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient psychotherapy services (90791, 90837) to 
be provided by an out of network provider. 
 
You asked the Plan to pre-approve the outpatient psychotherapy services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says there are network providers that can provide 
these services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
outpatient psychotherapy services (90791, 90837) to be provided by an out of network provider.