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 the clinical documentation provided 
supports the need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for 
coverage of LTACH care have not been met. The Plan says that the services needed could be provided in 
another setting. 
 
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. 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 health plan. 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan has to pre-approve cerebral perfusion analysis using computed tomography (CT). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cerebral perfusion analysis with CT is covered 
when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has recurrent transient 
ischemic attacks (TIAs) that have been challenging to manage. Perfusion deficits recur and the requested CT 
perfusion scan would identify areas of perfusion and hypoperfusion to help directly manage the enrollee's 
ongoing complications. The services are reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve cerebral perfusion analysis using computed tomography (CT).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical implant placements (D6010), bone grafts 
(D6104), implant/abutment (D6111) and precision attachments (D5862). 
 
You asked the Plan to pre-approve the surgical implant placements (D6010), bone grafts (D6104), 
implant/abutment (D6111) and precision attachments (D5862). You say that the dentist wants to put implants 
in to attach the plate permanently. You say that this is necessary to be able to eat not for cosmetic purposes. 
The Plan denied your request. The Plan says the 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 
surgical implant placements (D6010), bone grafts (D6104), implant/abutment (D6111) and precision 
attachments (D5862).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing 
provided on August 31, 2020. 
 
You asked the Plan to pay for genetic tests. You say that your lab performed all the tests ordered by the 
referring physician. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because this testing is not a Medicare benefit for the diagnoses listed and were done for screening 
purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
There is no documentation in the record of a specific concern for which this testing was ordered. This means it 
is screening in nature which is not covered by Medicare. Therefore, we decided that the Plan does not have to 
pay for molecular genetic hereditary predictive screening testing provided on August 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe radiology services with CPT code 77067 provided on August 25, 2020.You asked the Plan to pay forCPT code 77067. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. The file shows that the Plan paid for CPTcode 77067 for date of service August 25, 2020 on another claim. The records provided do not show that a second radiology service with CPT code 77067 was performed. The records provided are duplicates of one another.Therefore, we decided that the Plan does not have to pay forthe radiology services with CPT code 77067 provided on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided are neither emergent nor 
urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 had network providers 
available who could have provided 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 laboratory services provided on July 13, 2020 
by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from July 28, 
2020 through August 2, 2020. The Plan says, per Medicare guidelines, the provider should bill Original 
Medicare for the services rendered on August 6, 2020. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 2, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service provided on June 8, 2020. 
 
You asked the Plan to pay for the anesthesia service. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the documentation submitted did not include documentation of anesthesia 
administration with start and stop time to support the units billed. 
 
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 01402 is Anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty. 
 
We find that CPT code 01402 is not supported in the medical record. Specifically, there is no anesthesia note in 
the file to support the claim. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia service provided on June 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (TTE) 
provided on August 26, 2020. 
 
You asked the Plan to waive the copayment for TTE test. You say that this provider accepted your standard 
copayment of $35 and expect a refund for the difference. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 $125 
copayment for TTE test.  
 
You have been asked to pay $125 copayment for TTE test. TTE test falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 transthoracic echocardiography (TTE) provided on August 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Anoro Ellipta inhaler. 
 
You asked the Plan to pre-approve an Anoro Ellipta inhaler. You say that this is medically necessary. The Plan 
denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve an Anoro Ellipta inhaler.  
 
Benefits for an Anoro Ellipta inhaler may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says your request exceeds the mileage limit 
allowable. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, you have requested 
transportation for 61 miles for each one-way trip. However, the Plan contract only provides coverage for 50 
miles for each one-way trip. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spiriva. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spiriva.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on November 7, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on November 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the chest. 
 
You asked the Plan to pre-approve the scan. You say that this is supposed to be done every six months. The 
Plan denied your request. The Plan says follow-up imaging is not indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found there has been no 
change in nodules since 2014. A serial CT scan of the chest is no longer medically reasonable or 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 the scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the chest.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the speech therapy visit provided on 
August 24, 2020. 
 
You asked the Plan to reduce the copayment for the speech therapy visit. You say that it is your understanding 
that there is only a $10 copayment for therapy sessions. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing 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 $35 
copayment for each speech therapy visit.  
 
You have been asked to pay a $35 copayment for the speech therapy visit. The speech therapy visit falls within 
the Outpatient rehabilitation services 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 reduce the copayment 
for the speech therapy visit provided on August 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs and medical supplies 
provided on August 12, 2020. 
 
You asked the Plan to waive the coinsurance for Part B drugs and medical supplies. You say that there should 
be $0 copayment for outpatient surgery. The Plan denied your request. The Plan says you were charged the 
coinsurance 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 20% 
coinsurance for Part B drugs and Outpatient Supplies.  
 
You have been asked to pay 20% coinsurance for Part B drugs and medical supplies. Part B drugs and medical 
supplies fall within the Part B drugs and Outpatient Supplies 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 coinsurance for Part B drugs and medical supplies provided on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950), crown fused with metal tooth # 
18 and # 21 (D6752), and pontic porcelain fused hi noble tooth #19 & # 20 (D6240). 
 
You asked the Plan to pre-approve core build up, crown fused with metal and pontic porcelain fused hi noble 
tooth. You say that the service is medically necessary. The Plan denied your request. The Plan says the 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. Specifically, the services requested are not listed in the Plan?s benefit 
chart and, therefore, are not covered services. Therefore, we decided that the Plan does not have to pre-approve 
core build up (D2950), crown fused with metal tooth # 18 and # 21 (D6752), and pontic porcelain fused hi 
noble tooth #19 & # 20 (D6240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reconstruction of complete shoulder (rotator) cuff 
avulsion services coded 23420 and the bone marrow harvesting for transplantation services coded 38232 
provided on June 19, 2020. 
 
You asked the Plan to pay for the reconstruction of complete shoulder (rotator) cuff avulsion services and the 
bone marrow harvesting for transplantation 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 23420 and 38232 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a reconstruction of a complete shoulder (rotator) cuff avulsion, chronic 
(including acromioplasty); therefore, code 23420 cannot be verified. The operative report did not include 
documentation to meet the guidelines of autologous bone marrow harvesting for transplantation; therefore, 
code 38232 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 
reconstruction of complete shoulder (rotator) cuff avulsion services and the bone marrow harvesting for 
transplantation services have not been met. Therefore, we decided that the Plan does not have to pay for the 
reconstruction of complete shoulder (rotator) cuff avulsion services coded 23420 and the bone marrow 
harvesting for transplantation services coded 38232 provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the lower left and 
lower right quadrants, and a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says 1 scaling and root planing procedure per 3 calendar years, per quadrant is covered. 
The Plan says 1 lower denture per 5 calendar years is covered. The Plan also says that the frequency limits for 
these services have been reached. 
 
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 frequency limit of 1 scaling and 
root planing procedure per 3 years, per quadrant has been reached. The record shows that the Plan paid for 
scaling and root planing for the lower left and lower right quadrants that you received on August 14, 2020. 
Additionally, the frequency limit of 1 lower denture per 5 years has been reached. The record shows that the 
Plan paid for a partial lower denture that you received on May 7, 2017. Therefore, we decided that the Plan 
does not have to pre-approve scaling and root planing (D4341) for the lower left and lower right quadrants, and 
a partial lower denture (D5214).