Persius/hicric huggingface dataset:
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at an alternate level of care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the circulating tumor cell (CTC) testing provided on October 
1, 2019. 
 
You asked the Plan to pay for the CTC testing. You say that the services are reimbursable. The Plan denied 
your request. The Plan says the services are statutorily excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. There are been no substantive articles demonstrating clinical utility 
for this assay. Based on this information, we decided that Medicare rules for coverage of the CTC testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the circulating tumor cell (CTC) 
testing provided on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture.
You asked the Plan to pre-approve the lower partial denture. You say that this is not a pre-existing condition. You say that your implant fell out and you need a partial. The Plan denied your request. The Plan says the 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 pre-approve the lower partial denture.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services 
 
You asked the Plan to pre-approve SNF services. You say that the SNF level services are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee's 
needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the hearing aid purchased on September 20, 2019 from 
an out-of-network provider. 
 
You asked the Plan to reimburse for the hearing aid. You say that there are no providers in your area. The Plan 
denied your request. The Plan says the provider is not a part of the vendor network. 
 
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 reimburse for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
Review of the file show that you purchased the hearing aid on September 20, 2019 from an out-of-network 
provider. Your EOC states, "you may choose to order hearing aids either through the participating vendor 
network. Limited to two (2) hearing aids/devices every two years." 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 reimburse for these items/services. Therefore, we decided that the Plan does not have 
to reimburse for the hearing aid purchased on September 20, 2019 from an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that the additional visits are 
medically necessary. The Plan denied your request. The Plan says the additional visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found there is no indication that the enrollee's deficits could 
not be addressed with a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the echocardiography, transthoracic, complete with 
spectral Doppler and color flow Doppler to be provided by the requested facility. 
 
You asked the Plan to pre-approve the echocardiography, transthoracic, complete with spectral Doppler and 
color flow Doppler. The Plan denied your request. The Plan says the enrollee must receive care from in-
network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's 
service area or if the care cannot be provided with an in-network provider, which requires prior authorization 
from the plan.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested facility in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an 
echocardiography, transthoracic, complete with spectral Doppler and color flow Doppler to be provided by the 
requested facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings. 
 
You asked the Plan to pre-approve the compression stockings. You say that these stockings should be covered. 
The Plan denied your request. The Plan says compression stockings are considered a convenience item, 
primarily hygienic in nature or a device that is not primarily medical in nature and thus not covered. 
Additionally, you do not have a qualifying wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on April 9, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. 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 outpatient hospital services provided on April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve automatic grasp feature, addition to upper limb electric 
prosthetic terminal device (L6881). 
 
You asked the Plan to pre-approve addition to prosthetic device. You say that you request authorization for 
codes L6881 and L6882 because they are not bundled within the definition of L6880. The Plan denied your 
request. The Plan says this requested item 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 addition to prosthetic device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the microprocessor is not medically needed. The documentation does not 
show the need for this device. A standard prosthesis is ok. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of addition to prosthetic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve automatic grasp feature, addition to upper limb electric prosthetic terminal 
device (L6881).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve housekeeping/cleaning services. 
 
You asked the Plan to pre-approve housekeeping/cleaning services. You say that hemiparesis causes difficulty 
ambulating and has caused multiple falls. You say that the enrollee needs a housekeeper 2 hours per week. The 
Plan denied your request. The Plan says housekeeping/cleaning services are not considered medical services 
and are not covered for any reason. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of housekeeping/cleaning services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve housekeeping/cleaning services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance (A0429) and ground mileage 
(A0425) provided February 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that all ambulance transports require dual 
diagnosis codes. If the claims department could kindly review these claims and reprocess them. The Plan 
denied your request. The Plan says the records do not support medical necessity for the ambulance transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The documentation does not support that the enrollee required medical staff and 
specialized equipment only found in an ambulance. The documentation does not support that the enrollee 
required medical staff and specialized equipment only found in an ambulance. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency ambulance (A0429) and ground mileage (A0425) provided February 
20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zofran tablet, aspirins, Lorazepam tablet, and Toprol 
tablet provided on March 5, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not have any self-administered 
drugs because you are not allowed to take your own drugs into the hospital. The Plan denied your request. The 
Plan says you were prescribed self-administered drugs while you were in the emergency department. 
 
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 pay for the Zofran tablet, aspirins, 
Lorazepam tablet, and Toprol tablet provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a Reflexion 4 Queen-size adjustable bed and sales tax 
purchased on January 8, 2020 from a non-participating provider. 
 
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says you are requesting reimbursement of services rendered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
An adjustable bed is not primarily used to serve a medical purpose and would be useful to a person in the 
absence of illness or injury. Additionally, sales tax is not reimbursed by Medicare. The item at issue in this 
appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public 
and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not 
have to reimburse for a Reflexion 4 Queen-size adjustable bed and sales tax purchased on January 8, 2020 from 
a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraspinal manual manipulation (98943) and additional 
services (99199) provided on August 13, 2019 through September 24, 2019. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because 
these services were medically necessary. The Plan denied your request. The Plan says these services are not 
covered under your contract under any normal circumstances. 
 
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 extraspinal manual manipulation (98943) and additional services (99199) 
provided on August 13, 2019 through September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optometry services (92250, 92015, 92014) provided on 
July 30, 2019. 
 
You asked the Plan to pay for the optometry services.. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollee has no out-of-network vision benefits. 
 
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 optometry services (92250, 92015, 92014) 
provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 27, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on February 25, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you were under the impression that your dental policy included 2 visits per calendar year for cleanings and checkups. You also say that you were never informed that you could not have the cleaning and checkup while you had the rider because it would be deducted from the $1,000 max. The Plan denied your request. The Plan says your annual maximum benefit is exhausted.
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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on January 27, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on March 11, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this test should be reported with CPT 81479. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Guardant360 test provided to the enrollee on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient physician services provided on January 26, 
2020. 
 
You asked the Plan to pay for the inpatient physician services. You say that the records support that this code is 
correct. The Plan denied your request. The Plan says the enrollee was not an inpatient at the time these services 
were rendered. As such, the inpatient visit code cannot be paid. 
 
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 code 99233 is not supported in the medical record. Specifically, this code is reported for 
services provided to a hospital inpatient. The enrollee was an outpatient at the time these services were 
rendered. Based on this information, we decided that Medicare rules for coverage of the inpatient physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient physician 
services provided on January 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing for the 
enrollee. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test should be reported with CPT 81479. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 pay 
for Comprehensive Genomic Profile (CGP) testing for the enrollee.