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

 
We decided that the Plan does not have to pay for the medical services provided on February 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the CPAP and supplies. You say that the claim should be paid. The Plan denied 
your request. The Plan says there was no network deficiency for these services, in network providers were 
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 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 the medical services provided on February 27, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve the mastectomy sleeve. You say that the sleeve is medically necessary. The 
Plan denied your request. The Plan says the requested item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as non-
covered, since it does not meet the definition of a prosthesis.  
 
We looked at the file and Medicare rules. The requested item is not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of the mastectomy sleeve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional occupational therapy (OT) visits (G0152). 
 
You asked the Plan to pre-approve 5 additional OT visits. You say that continued OT is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of continued OT 
services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 5 additional OT visits. Our reviewer 
says that 5 additional OT visits are not medically necessary at this time. Our physician reviewer found 
the records do not show that skilled therapy services are required to effectively provide treatment, care, and/or 
services in order to improve the patient's level of function, or to establish/perform a maintenance program to 
maintain the patient's level of function and/or prevent deterioration.  
 
 
The patient has had prior therapy and the patient's functional level does not require ongoing skilled therapy. 
She is compliant in her home exercise program and met her long-term goals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 additional occupational therapy (OT) visits (G0152).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima (Q5115). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the member needs to try Rituxan (rituximab) or Ruxience (rituximab-pvvr) before 
this medication 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 the medication. Our physician reviewer 
found the member has not tried Rituxan (rituximab) or Ruxience (rituximab-pvvr). The documentation does not 
support that Rituxan (rituximab) or Ruxience (rituximab-pvvr) would likely be less effective, and/or would 
likely have adverse effects for 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Truxima (Q5115).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vitrectomy recovery chair. 
 
You asked the Plan to pre-approve a vitrectomy recovery chair. You say that the item is necessary. The Plan 
denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has 
not been met. 
 
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 a vitrectomy recovery chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is the LTACH primary role to care for 
critically ill patients requiring extended acute care. They are specially equipped to provide long term care and 
would be a preferred setting to continuation at a short-term care hospital. The Plan denied your request. The 
Plan says an LTACH is not able to provide any service that cannot be provided in the current setting. There is 
no clinical benefit to LTACH care for a long-term acute care patient. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is an 80-year-old male who was admitted to the current acute care hospital 
with traumatic fall, syncope, and cervical spine fracture. He underwent ACDF C3-5 with extension, and code 
stroke was called during the procedure. However, the CT of the head did not show any stroke process. He was 
not able to be extubated and underwent tracheostomy and NG tube. Recent notes show only short-term success 
with trach collar before requiring ventilator support again. He still requires IV antibiotics due to active 
infection. 
 
The patient appears to be requiring additional short-term acute care services to complete treatment with 
antibiotics and PEG placement and continue weaning which can be safely performed at the current facility. The 
patient does not require services at the LTACH that are not already available at the current facility. Therefore, 
this request for LTACH services will be considered not medically necessary at this time. Transfer may be 
considered when the patient is more stable. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjunctive pre-diagnostic test (D0431), core buildup, 
including any pins when required for teeth # 5, 8, 11 and 30 (D2950), gingival irrigation - per quadrant 
(D4921), pontic - porcelain/ceramic for teeth # 9 and 10 (D6245), retainer crown - porcelain/ceramic for teeth # 
8 and 11 (D6740), and other drugs and/or medicaments (D9630). 
 
You asked the Plan to pre-approve adjunctive pre-diagnostic test, core buildup, including any pins when 
required for teeth # 5, 8, 11 and 30, gingival irrigation - per quadrant, pontic - porcelain/ceramic for teeth # 9 
and 10, retainer crown - porcelain/ceramic for teeth # 8 and 11, and other drugs and/or medicaments. You say 
that the services are necessary. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
 
 
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
adjunctive pre-diagnostic test (D0431), core buildup, including any pins when required for teeth # 5, 8, 11 and 
30 (D2950), gingival irrigation - per quadrant (D4921), pontic - porcelain/ceramic for teeth # 9 and 10 
(D6245), retainer crown - porcelain/ceramic for teeth # 8 and 11 (D6740), and other drugs and/or medicaments 
(D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from January 13, 2020, 
through May 12, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says with 
limited exceptions, while you are a member of the Plan, you must receive care from in-network providers with 
the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the 
care cannot be provided with an in-network provider, which requires prior authorization from the plan.  
 
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 
chiropractic 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 chiropractic services provided from January 13, 2020, 
through May 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transport services provided to the enrollee on November 17, 
2019. 
 
You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should 
be submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
transport services provided to the enrollee on November 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection, expandable controller and 
harness, and power seat elevation system for a power wheelchair (PWC). 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that The rules say that a power seat elevation feature 
(E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
The rules say that if a PWC base is not covered, the accessories will not be covered. 
 
The services at issue are a power seat elevation system, an electronic connection, and an expandable controller 
and harness. The power seat elevation system is denied by Medicare as non-covered. The electronic connection 
and expandable controller with harness are not needed to control the approved power options through the 
joystick. Therefore, we decided that the Plan does not have to pre-approve an electronic connection, 
expandable controller and harness, and power seat elevation system for a power wheelchair (PWC).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on March 11, 2020. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says in 
most cases, care you receive from an out-of-network provider will not be covered except for emergency or 
urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an 
in-network provider, which requires prior authorization from the plan. 
 
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 
physical therapy 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 physical therapy services on provided on March 
11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xofigo. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Xofigo is FDA-approved for the 
treatment of castration-resistant prostate cancer in patients with symptomatic bone metastases and no known 
visceral metastatic disease. There are no off-label indications. This enrollee has no focal pain consistent with 
painful pain metastases. Use of this medication may also preclude the ability to receive cytotoxic therapy in the 
future, given his borderline platelet count. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Xofigo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 6, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the doctor did nothing to 
reschedule your surgery. You say that you shouldn't be charged. The Plan denied your request. The Plan says 
the copayment applied 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 $50 
copayment per visit for a specialist office visit.  
 
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you 
were seen at the specialist's office for a follow up for neuropathic left lower extremity pain. 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 office visit provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 25, 2020 and 
August 31, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, you must use network providers to get your medical care and services. The only exceptions 
are emergencies, urgently needed services when the network is not available (generally, when you are out of 
the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers. 
 
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 
physician's 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 physician's services provided on August 25, 2020 and August 
31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on February 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services to be provided by the out-of-network provider. The 
Plan denied your request. The Plan says the service is available within the network and your condition is not an 
emergency. 
 
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 
physician's services to be provided by the out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 6, 
2020, to March 6, 2020. 
 
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your 
request. The Plan says the enrollee did not meet Medicare criteria for coverage of SNF care. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary did not require skilled 
nursing or therapy services daily 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 6, 2020, to March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan.  
 
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 
physician's services to be provided by the out-of-network provider.