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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and ready for 
transfer to a LTACH. The Plan denied your request. The Plan says it is not medically necessary for transfer of 
care to a LTACH. 
 
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 enrollee does not require services at the LTACH that are not already provided at 
the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that 
are not already available and covered in the current facility. Our physician reviewer also found that transfer 
may be considered soon. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on August 10, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that you were not told this provider was not in 
network. The Plan denied your request. The Plan says this was not authorized. 
 
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 office visit (99203) provided on August 10, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite provided by an out-of-network 
provider on March 10, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you wouldn't have gone to your 
appointment if you knew you had to pay the cost. You say that the claim should be approved. The Plan denied 
your request. The Plan says dental services are excluded from coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite provided by an out-of-network provider on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 87641, 87798, and 87900 provided on November 11, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 87641, 87798, and 87900 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 87641, 87798, and 87900 provided on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive genomic profile provided. 
 
You asked the Plan to pay for the comprehensive genomic profile. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the comprehensive genomic profile is not supported in the medical record. Specifically, this 
service should be coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered 
adjacent to the code in the comment/narrative field. Based on this information, we decided that Medicare rules 
for coverage of the comprehensive genomic profile have not been met. Therefore, we decided that the Plan 
does not have to pay for the comprehensive genomic profile provided.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 skilled nursing visits, 7 physical therapy visits, 10
occupational visits, and 13 home health aide visits.
You asked the Plan to pre-approve 20 skilled nursing visits, 7 physical therapy visits, 10 occupational visits,
and 13 home health aide visits. 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 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 20 skilled nursing visits, 7 physical
therapy visits, 10 occupational visits, and 13 home health aide visits. Our reviewer says that the documentation
does not support that the requested services are medically reasonable or necessary. Our physician reviewer
found you have had extensive prior skilled nursing and was educated in disease management. Your wounds are
chronic without signs of infection. There are no complex wound care needs, new enteral feedings or other
skilled nursing need. The records do not show that skilled therapy is needed to effectively provide treatment,
care, and/or services in order to improve your level of function, or to establish/perform a maintenance program
to maintain your level of function and/or prevent deterioration beyond what was approved by the health plan.
Your functional level does not require ongoing skilled therapy. Therefore, you do 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 20 skilled nursing visits, 7 physical therapy visits, 10 occupational visits, and 13
home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 20
skilled nursing visits, 7 physical therapy visits, 10 occupational visits, and 13 home health aide visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for a stress test. We decided that the Plan does not have 
to waive the copayment for a stress test.  
 
You asked the Plan to waive the copayment for a stress test. You say that you were told that this test was 
covered. You say that no one mentioned a $160 copayment. The Plan says that the correct copayment has been 
applied. 
 
We decided that the Plan has to reduce the copayment for a stress test.  
 
You cannot be asked to pay more than a $20 copayment for a stress test. 
 
We also decided that the Plan does not have to waive the copayment for a stress test. 
 
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 a stress test. Therefore, we decided that the Plan does not have to waive the copayment for a 
stress test. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 subsequent nursing facility care provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses provided on June 15, 2020. 
 
You asked the Plan to pay for the contact lenses. You say that you should not be penalized for something that 
was not your fault. The Plan denied your request. The Plan says the cost of services exceed the allowed 
amount. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The total cost for the contact lenses at issue was $249. The Plan paid 
$150, which is the maximum allowed amount for your supplemental vision benefit. This leaves a remaining 
balance of $99. We found no exception which would require the Plan to pay additional costs for the provided 
contact lenses. Therefore, we decided that the Plan does not have to further pay for the contact lenses provided 
on June 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is at a functional level to safely discharge to home or other 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found as of 11/15/20, the enrollee did not 
require any skilled nursing or rehab services on daily basis. 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 ADLs. The enrollee did not require skilled therapy to establish a safe and effective maintenance 
program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF 
level of care as of 11/15/2020. 
 
 
 
 
 
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) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additional reimbursement for hearing aids purchased out-of-
network on August 13, 2020. 
 
You asked the Plan to pay additional reimbursement additional reimbursement. You say that the Plan should 
contribute more toward these hearing aids. The Plan denied your request. The Plan says you did not purchase 
TruHearing Advanced or Premium hearing aids therefore the $499 and $799 copay does not apply. The Plan 
says that you purchased ?other hearing aids? (not the TruHearing Advanced or Premium hearing aids) from a 
non-contract provider.  The Plan paid the $500 allowance for the hearing aids purchased out of network.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan contract 
clearly states that hearing aids purchased from the preferred provider will only be given the $500 allowance. 
This has been paid. Medicare does not make exceptions to contract rules for hearing aids. You chose not to use 
the preferred vendor provided by the Plan that would have yielded a higher benefit. Therefore, we decided that 
the Plan does not have to pay additional reimbursement for hearing aids purchased out-of-network on August 
13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nursing facility care (99309) provided on 
March 11, 2020, by an out-of-network provider. 
 
You asked the Plan to waive the copayment for nursing facility care. You say that you disagree with the cost 
share. The Plan denied your request. The Plan says the cost share was 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 $5 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $5 copayment for nursing facility care. The nursing facility care 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 nursing facility care (99309) provided on March 11, 2020, by an out-of-network 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone scan whole body (78306). 
 
You asked the Plan to pre-approve a bone scan whole body. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bone scan whole body. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found it is barely 2 months since the 
last bone scan and increased activity would certainly be expected in the left scapular fracture and it would be 
expected that there would be further increased activity in the left fibular fracture due to the bone biopsy which 
was done October 2, 2020 regardless of whether the lesion was malignant or not. The other areas of 
intermediate activity described look like classic degenerative changes in common locations. Further 
surveillance is certainly indicated in this enrollee with a history of lung cancer but a repeat radionuclide bone 
scan only 2 months after an identical scan and 6 weeks after a bone biopsy is not 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 a bone scan whole body have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone scan whole body (78306).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you went to urgent care after the medics 
treatment in place. 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 January 15, 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 January 15, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the corneal tissue provided on June 10, 
2020. 
 
You asked the Plan to waive the cost share for the services provided. You say that corneal tissue is not medical 
equipment. The Plan denied your request. The Plan says the coinsurance was correctly assessed. 
 
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% 
coinsurance for prosthetic devices and related supplies.  
 
You have been asked to pay a $50 copay for outpatient surgery services. The services fall within the outpatient 
surgery benefit category. You have been asked to pay a 20% coinsurance for the corneal tissue provided during 
surgery. The services fall within the prosthetic devices and related supplies benefit category. Your contract 
with the plan says that you pay a cost share each time you receive certain medical services. 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 cost share for the corneal tissue provided on June 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the device is experimental. More research is needed to show safety and 
efficacy of the device. It is not the care standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869, 22870).