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

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 15, 2020 
to March 15, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
did not need skilled medical care or skilled nursing 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 the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 15, 2020 to March 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397), a 
shoulder-hand-wrist orthosis (L3960), and a lumbar-sacral orthosis (L0648) provided to the enrollee on 
December 5, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered.  
 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, 
L2397), a shoulder-hand-wrist orthosis (L3960), and a lumbar-sacral orthosis (L0648) provided to the enrollee 
on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 30, 2020.
You asked the Plan to pay for the office visit. You say that you were told your insurance would be accepted. The Plan denied your request. The Plan says the service is not covered.
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. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 4, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician?s intent that the tests be performed. 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 pay for the 
drug testing services provided on June 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve EUFLEXXA (J7323). 
 
You asked the Plan to pre-approve EUFLEXXA. You say that you meet criteria for coverage. The Plan denied 
your request. The Plan says you have not tried conservative therapy. 
 
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 EUFLEXXA. Our reviewer says that 
EUFLEXXA is not medically necessary at this time. Our physician reviewer found there is no documentation 
of adequate conservative measures for knee pain treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EUFLEXXA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve EUFLEXXA (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6532. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are necessary. The 
Plan denied your request. The Plan says there was no documentation of any open venous stasis ulcers or 
qualifying wounds. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6532.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical and occupational therapy services (97110, 
97112, 97116, 97140, 97162, 97166, 97530, 97535, 97542, G0283) provided on August 21, 2019 to October 
18, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physical and occupational therapy services. You say that you did not know the 
patient had an HMO Plan when she began treatment. The Plan denied your request. The Plan says these 
services were 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 physical and occupational therapy services 
(97110, 97112, 97116, 97140, 97162, 97166, 97530, 97535, 97542, G0283) provided on August 21, 2019 to 
October 18, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 25, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 pay for the drug testing services provided on June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided March 
13, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says the records do not support the billed 
service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid itemized shipping/billing invoice to indicate the specific supplies or proof 
of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for shoulder elbow wrist hand orthosis (L3960) provided March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a JAS Dynamic Shoulder Range of Motion Device (E1840). 
 
You asked the Plan to pay for the orthosis. You say that the enrollee requires the device due to loss of motion 
in her arm. The Plan denied your request. The Plan says the shoulder device as a lack of scientific evidence 
regarding its effectiveness for the patient's shoulder. 
 
The Plan must follow Medicare rules. Medicare rules say that experimental and investigational devices are not 
covered.  Items and services which are not reasonable and necessary for the diagnosis or treatment of illness or 
injury or to improve the functioning of a malformed body member are not covered. This device is considered 
experimental. Therefore, the request for the JAS Dynamic Shoulder Range of Motion Device does not meet 
medical necessity criteria. Therefore, we decided that the Plan does not have to pay for a JAS Dynamic 
Shoulder Range of Motion Device (E1840).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the two crowns (D2740 x2) and two core buildups, 
including any pins when required (D2950 x2). 
 
You asked the Plan to pre-approve the crowns and core buildups. You say that the crowns and core buildups 
are required to restore the enrollee's teeth. The Plan denied your request. The Plan says these services are not 
covered benefits. 
 
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 the 
two crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on February 7, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for an OON rest home visit. You say that the doctor is not responsible for 
authorization. The Plan denied your request. The Plan says OON require 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 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 rest home visit (99336) provided on February 
7, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary to get a definite answer 
regarding the nodules that are present. The Plan denied your request. The Plan says the requested services do 
not meet medical necessity coverage in this scenario. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records are of insufficient quantity and quality to support the medical necessity of the 
requested service. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genetic testing for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve extractions (D7140) of tooth #'s 4 through 31 in a hospital setting. 
 
You asked the Plan to pre-approve the extractions in a hospital setting. You say that you have a lot of medical 
complications. The Plan denied your request. The Plan says that the requested service is not covered under the 
supplemental 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. The Plan covers the 
extractions when the services are medically necessary and reasonable. 
 
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 extractions. Our reviewer says that 
the service is medically necessary. Our physician reviewer found due to your extensive medical history, it is 
medically reasonable and necessary that the extractions be carried out in a hospital setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the extractions have been met. Therefore, we decided that the Plan has to pre-
approve extractions (D7140) of tooth #'s 4 through 31 in a hospital setting.  
 
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 the DME provided on March 10, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the documentation 
submitted did not include proof of delivery for the billed codes. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the DME provided on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 5, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says lab results have 
not been submitted for the billed date of service. 
 
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 testing is not supported in the medical records. The documentation provided does not include 
results of the billed testing. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 5, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee from 
January 1, 2020 through January 20, 2020 provided by an out-of-network provider. 
 
You asked the Plan to waive the copayment for SNF care. You say that you would like this to be billed as in-
network. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 
2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that the enrollee received SNF care from January 1, 2020 through January 20, 2020 
provided by an out-of-network provider. The enrollee is asked to pay a $195 copayment each day for any out-
of-network SNF care from days 1 through 35. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
SNF care provided to the enrollee from January 1, 2020 through January 20, 2020 provided by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac joint injection billed for services provided on 
March 9, 2020. 
 
You asked the Plan to pay for the billed services. You say that the procedure codes and diagnosis on the 
records were exactly what was billed. The Plan denied your request. The Plan says the billed services cannot be 
verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27096 is injection procedure for sacroiliac joint, 
anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. We find 
that CPT code 27096 is not supported in the medical record. Specifically, the billed services have not been 
corroborated by the documentation provided. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the sacroiliac joint 
injection billed for services provided on March 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc (J7325). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc.
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 Synvisc (J7325). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found there is no documentation of the patient not being able to tolerate first line therapy with Monovisc or Orthovisc. Criteria for Synvisc is not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study on February 25, 2020. 
 
You asked the Plan to waive the copayment for the radiological diagnostic service. You say that you are 
appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan 
says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received a duplex scan of extremity veins including responses to compression 
and other maneuvers; unilateral or limited study on February 25, 2020. The Medicare-allowed amount for the 
radiological diagnostic service is less than the set $155 copayment; therefore, you have been asked to pay the 
lesser amount of $144.03 for the duplex scan. Your EOC states that enrollees must pay a $155 copayment for 
each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office 
or at a free-standing facility (such as a radiology center or medical clinic). 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 duplex scan of extremity veins including responses to compression and other 
maneuvers; unilateral or limited study on February 25, 2020.