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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from 9/23/20 and forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from 9/23/20 and forward. You say that the 
continuation of inpatient psychiatric care from 9/23/20 and forward is medically necessary. The Plan denied 
your request. The Plan says the continuation of inpatient psychiatric care 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 psychiatric care from 9/23/20 
and forward. Our reviewer says that the continuation of inpatient psychiatric care is not medically necessary. 
Our physician reviewer found this enrollee was admitted to the acute inpatient psychiatric hospital on 
September 4, 2020 with Major Neurocognitive Disorder with Behavioral Disturbance. Based upon review of 
the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the 
dates in question as he was not showing any dangerousness to self or others, no auditory or visual 
hallucinations and no abnormal behaviors. This enrollee was compliant with treatment. 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 he did not have any suicidal or homicidal thoughts, 
hallucinations or aggressive behaviors. 
 
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 psychiatric care from 9/23/20 and forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from 9/23/20 and 
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) to be rendered by the out of 
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit (99203) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns for tooth #'s 25 and 26. 
 
You asked the Plan to pre-approve the crowns for tooth #'s 25 and 26. You say that the enrollee lost the crowns 
and will lose the teeth without them. The Plan denied your request. The Plan says the services are only allowed 
once every five years. 
 
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 also have a maximum benefit 
of one crown per tooth every 5 years. The Plan paid for a crown for tooth #'s 25 and 26 provided on July 19, 
2018. Therefore, we decided that the Plan does not have to pre-approve the crowns for tooth #'s 25 and 26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve the BRCA testing. You say that the enrollee's mother died in her 30s of 
ovarian cancer and her brother has had lung cancer. This family history makes this testing medically necessary. 
The Plan denied your request. The Plan says this is not covered since the enrollee has no personal history of 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered for enrollees with a 
personal history of certain cancers. This testing is not covered for those without a personal history of cancer as 
this is considered screening testing which is not covered by Medicare.  
 
Although this testing may be appropriate based on family history, Medicare does not cover this testing in this 
circumstance. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional chiropractic services. 
 
You asked the Plan to pre-approve additional chiropractic services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 additional chiropractic services Our 
reviewer says that the documentation does not support that the requested chiropractic services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has undergone chiropractic treatment. The 
documentation does not support evidence of subluxation. In addition, the check off x-ray report reveals, 
mainly, arthritic/degenerative type findings, for which chiropractic can do little. The submitted chart notes 
reveal no evidence of improvement, with no evidence that further improvement is likely with continued 
chiropractic care. Therefore, the enrollee does not meet criteria for the requested 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 additional chiropractic services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 10 additional chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have accidents every day. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ambulatory surgical boot. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 an ambulatory surgical boot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator, rental (CPT Code 
E1392). 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says the medical records received did not indicate 
you meet the criteria. 
 
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 portable oxygen concentrator. Our 
physician reviewer found coverage criteria for a portable oxygen concentrator are not met. You have morbid 
obesity, diabetes, depression, and chronic pain.  Chronic obstructive pulmonary disease (COPD) is mentioned 
as a diagnosis occasionally in the record, but there are no pulmonary function data to support it. There is 
occasional mention of a home oxygen concentrator, but there are no data in the record to support a need for 
home supplemental oxygen. Oxygen saturations during clinical visits over more than 2 years are generally 96 
to 98% breathing room air. There is one oxygen saturation of 77% (12/3/2018), but that appears to be an error 
and is not mentioned elsewhere in the note. There are no oxygenation data during sleep or with exercise. You 
are apparently wheelchair bound. Supplemental oxygen, and a portable oxygen concentrator, are not medically 
necessary based on the clinical information available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve portable oxygen concentrator, rental (CPT Code E1392).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested drug. 
 
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 Prolia. 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 age related osteoporosis without current pathological fracture. The 
documentation does not support a history if an osteoporotic fracture or previous treatment, contraindication, or 
intolerance to zoledronic acid. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy (OT) services (97530, 
97035). 
 
You asked the Plan to pre-approve the additional OT visits. You say that the services are medically necessary. 
The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional OT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the patient has been educated in a home exercise 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 patient'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 the additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupational therapy (OT) services (97530, 97035).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brow ptosis repair to be done in conjunction with 
other eyelid surgical procedures. 
 
You asked the Plan to pre-approve the brow ptosis repair. You say that all requested services should be 
approved due to medical necessity. The Plan denied your request. The Plan says the documentation does not 
include the required elements for coverage of the brow repair. 
 
The Plan follows Medicare rules. Medicare rules say that brow ptosis repair may be covered when the above 
referenced criteria are met.  
 
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 brow ptosis repair. Our reviewer 
says that the requested surgical correction is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the medical records and photographs do not support that the enrollee's visual 
impairment would not be sufficiently corrected by blepharoplasty/blepharoptosis. There is not drooping of the 
eyebrows such that excess tissue is being pushed onto the upper eyelid. 
 
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 brow ptosis repair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a brow ptosis repair to be done in conjunction with other eyelid surgical 
procedures.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hydroxychloroquine sulfate. 
 
You asked the Plan to pre-approve hydroxychloroquine sulfate. You say that the medication is medically 
necessary. The Plan denied your request. The Plan says this is not covered under the enrollee's Part B plan. 
 
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 hydroxychloroquine sulfate.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 300/2ml Dupixent injection. 
 
You asked the Plan to pre-approve the Dupixent. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the requested medication is not covered 
under Medicare 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 a 300/2ml Dupixent 
injection.  
 
Benefits for the Dupixent 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 7, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that the emergency room told you to 
return for a follow-up so you did. You state that you were told you would not owe a copayment for the second 
copayment. 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 $110 
copayment for emergency care.  
 
You have been asked to pay the allowed amount of $81.60, which is less than the $110 copayment for 
emergency care. Emergency care falls within the emergency 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 copayment for emergency care provided on June 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on February 21, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that your left leg is longer than the right after surgery. 
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 pay for foot orthotics provided on February 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 14, 2020 to March 20, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that this stay 
was related to a previous stay and you should not be responsible for the charges. 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 $390 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 14, 2020 to March 20, 2020. This is considered a new inpatient 
stay. Therefore, you are responsible to pay a $390 copayment for days 1-5 (March 14, 2020 to March 18, 
2020). $390 (copayment) x 5 (inpatient days) = $1,950.  
 
You have been asked to pay the total copayment amount of $1,950 for an inpatient hospital stay. An inpatient 
hospital stay falls within the 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 
copayment for an inpatient hospital stay provided from March 14, 2020 to March 20, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Emergency Room visit (99285) 
provided May 18, 2020. 
 
You asked the Plan to waive the copayment for the Emergency Room visit. You say that you should only be 
charged the urgent care copayment. The Plan denied your request. The Plan says the correct copayment 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 $110 
copayment for Emergency Care.  
 
You have been asked to pay a $110 copayment for the Emergency Room visit. The Emergency Room visit falls 
within the Emergency 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 copayment for an 
Emergency Room visit (99285) provided May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the orthopedic office visit (99213) provided 
on March 6, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $45 copayment for the specialist office visit. 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 the orthopedic office visit (99213) provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided from May 21, 2020 to 
May 23, 2020. 
 
You asked the Plan to pay for the subsequent hospital care (99231). You say that the services were for 
treatment outside the global diagnosis and are separately billable. The Plan denied your request. The Plan says 
the denied claims have been billed with the same diagnosis codes as the surgical claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99231 is not supported in the medical record. Specifically, the enrollee was treated 
during the subsequent hospital care for the same diagnosis treated during the inpatient stay. Based on this 
information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided from May 
21, 2020 to May 23, 2020.