Persius/hicric huggingface dataset:
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for complications related to end-stage renal disease. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided by a 
participating provider on October 30, 2020. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says the correct copayment has been 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 $50 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $50 copayment for a specialist telehealth visit. A specialist telehealth visit falls 
within the physician/practitioner services/specialist 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 telehealth visit provided by a participating provider on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on September 10, 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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 panel rendered on September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 patient was admitted for weakness and urinary tract infection. Medical problems 
are stable. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable 
expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3330) provided on November 3, 2020. 
 
You asked the Plan to pay for the dental service. You say that the service denied in error. You say that the Plan 
will reimburse 100% of the allowed amount for procedures performed out of network. You say that the allowed 
amount for a molar root canal is $540. You also say that the plan should pay $540. The Plan denied your 
request. The Plan says root canal is not listed as a covered service. The Plan says that you were emailed a list of 
covered services. The Plan also says that you contacted the Plan after the service was rendered. 
 
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, root canal is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3330) provided 
on November 3, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says care can be received in another setting, such as home, a long-term care facility, or 
other outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the admission. 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. You do not require skilled nursing or 
therapy services on a daily basis. You do not not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need a new denture 
approved. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per 
period. 
 
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, maxillary partial denture (D5213) is 
limited to one procedure every five plan years. The record shows that you received a maxillary partial denture 
(D5213) on June 30, 2020 and your maxillary partial denture (D5213) benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place and 
triaged to BLS. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 1, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 1, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the enrollee is currently on this medication, and needs 
to continue with treatment. The Plan denied your request. The Plan says this request does not meet Part B 
coverage criteria for Retacrit. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Retacrit. Our reviewer says that 
Retacrit (Q5106) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee was started on Retacrit therapy and has not met target hemoglobin in over 8 weeks. On March 17, 
2021 Ferritin was 87.5 and on March 10, 2021 Transferrin saturation was 12% anemia of chronic disease and 
iron deficiency. Our reviewer found that the drug is not being used under the medically accepted standard(s) of 
documentation of a transferrin level of at least 20% and a ferritin of at least 100 ng/ml, within the last 4 
months. The review has determined that the requested use of Retacrit (Q5106) is FDA-approved for the 
enrollee's diagnosis. Our physician reviewer also found that the use of Retacrit presently is not supported by 
one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services approved medical journal 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services provided on 
November 11, 2020. 
 
You asked the Plan to waive the copayment for ophthalmology services. You say that this was your annual eye 
exam and you should not owe a 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 $40 
copayment for specialist visits. 
 
You received ophthalmology services on November 11, 2020. Ophthalmology services are considered 
specialist services and are subject to cost-sharing charges. Therefore, you are responsible to pay the $40 
copayment.   
 
You have been asked to pay a $40 copayment for ophthalmology services. Ophthalmology services fall 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 ophthalmology services provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight testing (81479, 81291) provided on February 18, 
2020. 
 
You asked the Plan to pay for GeneSight testing. You say that this is a Medicare-covered service. The Plan 
denied your request. The Plan says this is only covered for beneficiaries with major depressive disorder. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing may only be ordered by 
licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for 
patients diagnosed with major depressive disorder (MDD) who are suffering with refractory moderate to severe 
depression after at least one prior neuropsychiatric medication failure.  
 
We looked at the file and Medicare rules. The records show that the enrollee has not been diagnosed with 
major depressive disorder. Based on this information, we decided that Medicare rules for coverage of 
GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight 
testing (81479, 81291) provided on February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D9250) provided on October 14, 2020. 
 
You asked the Plan to pay for the dental service. You say that the core build up is extremely important in 
getting the right fit for your teeth. You also say that you cannot afford the prices that the dentist charges. You 
say that The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan 
also says that there is no indication that you contacted the Plan prior to the date of service to verify benefits and 
provider eligibility. 
 
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, core build up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D9250) provided on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Interspinous spacer device. 
 
You asked the Plan to pre-approve the spacer device. The Plan denied your request. The Plan says this 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 the spacer device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the spinous process interlaminar spacer is experimental. More research is needed to show 
safety and efficacy of the device. 
 
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 spacer device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Superion Interspinous spacer device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan and myocardial perfusion 
imaging provided on December 8, 2020. 
 
You asked the Plan to waive the copayment for the CT scan and myocardial perfusion imaging. You say that 
these are pre-operative tests that were ordered by the surgeon. You say that this is creating a hardship and 
insurance should be paying. The Plan denied your request. The Plan says the copayments 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 $250 
copayment for each Medicare-covered diagnostic imaging service. 
 
You have been asked to pay a $250 copayment for the CT scan and a $250 copayment for the myocardial 
perfusion imaging. The total amount you owe is $500 $250/scan x 2 scans = $500). The CT scan and 
myocardial perfusion imaging fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 
benefit category. There is no provision in the contract which indicates a copayment would be waived if 
performed as a pre-operative service. 
 
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 CT scan and myocardial perfusion imaging provided on 
December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the skilled nursing facilities in the 
enrollee's area do not provide the services that the enrollee needs. The Plan denied your request. The Plan says 
the LTACH services you are requesting do not meet the requirements for approval. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that the enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the Plan. Our physician reviewer also found that the requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on November 25, 
2020. 
 
You asked the Plan to pay for the AWV. The Plan denied your request. The Plan says the benefit limit has been 
exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided on June 8, 2020, less than 12 months prior to the visit at 
issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) 
you had on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided 
on August 22, 2020. 
 
You asked the Plan to pay for the core buildup. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service is 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 pay for the core 
buildup, including any pins when required provided on August 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve conscious sedation with a spinal injection for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of fear of avoidance or comorbidities that would necessitate 
this procedure. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the requested epidural steroid injection with sedation is not considered 
medically necessary in this case. Though the patient has a history of low back pain with radicular symptoms 
and previously had prior relief with previous injections, there was no indication as to the medical necessity of 
the requested anesthesia. The review has determined that the requested conscious sedation is not appropriate 
for this injection. 
 
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 conscious sedation with a spinal injection for the enrollee.