Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 portable ventilator. Our reviewer says
that the requested portable ventilator is not medically necessary. Our physician reviewer found you have
obesity-hypoventilation syndrome (OHS). You do not have a covered diagnosis such as severe COPD with
CO2 retention or neuromuscular disease. Medicare does not cover a ventilator for the treatment of OHS.
Therefore, you do not meet criteria for the requested item.
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 portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator.
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 services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the complexity of the enrollee's 
nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for a hip fracture and clavicular 
fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record does document a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve the range of motion assist device. You say that you would like 
reconsideration because the member has exhausted all other forms of rehabilitation. The Plan denied your 
request. The Plan says this device is investigational. 
 
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 range of motion assist device. 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 unproven and experimental or investigational. 
 
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 range of motion assist device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee has stabilized medically and no longer requires daily 
skilled therapies and does not require skilled therapies for maintenance. 
 
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 that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telemedicine cardiology visit provided on 
June 10, 2020. 
 
You asked the Plan to waive the copayment for specialist visit. You say that this visit was for 1 minute just to 
say that your electrocardiogram (EKG) was good, which your internist doctor could have seen. 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 $45 
copayment for specialist visit.  
 
You have been asked to pay $45 copayment for specialist visit. Specialist visit 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 a telemedicine cardiology visit provided on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePeripheral Neuropathy Expanded Panel.You asked the Plan to pre-approvePeripheral Neuropathy Expanded Panel. 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 follows Medicare rules. Medicare rulessay that Peripheral Neuropathy Expanded Panel is only covered for certain indications.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 Peripheral Neuropathy Expanded Panel. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you began to have peripheral neuropathy symptoms beginning in the years prior to 2016. The symptoms had primarily affected your feet and fingers. You have tried Gabapentin but stopped the treatment as it was not beneficial. During chemotherapy, the progression was thought to be due to the chemotherapy. However, the progressive nature of the neuropathy did not abate after chemotherapy ended. The literature indicates that in the Medicare National Coverage Analysis (NCA) for Next Generation Sequencing (NGS), it states that NGS is only covered for enrollees withAdvanced Cancer. Your peripheral neuropathy is not related to your Hodgkin's lymphoma or the chemotherapy used to treat as your peripheral neuropathy pre-dated your diagnosis and treatment for Hodgkin's lymphoma. 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 Peripheral Neuropathy Expanded Panel have not been met.Therefore, we decided that the Plan does not have to pre-approvePeripheral Neuropathy Expanded Panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.You asked the Plan to pre-approvethe complete maxillary and mandibular dentures. You say that you did not receive a partial in 2018. You also say that it was 2014 when you got your partial.The Plan denied your request. The Plan says you have exhausted your denture 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, dentures are covered once per arch every 5 years. The record shows that you received a maxillary partial denture and a mandibular partial denture on March 29, 2018, and your dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 4, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not covered. 
 
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 the lab services provided on 
February 4, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for outpatient services provided on January 6, 2020, through January 7, 
2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says that payment for this 
service is the responsibility of the facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan's denial reason is not substantiated as this is an outpatient claim being 
billed by the facility. There is insufficient information to determine if this denial is appropriate Therefore, we 
decided that the Plan has to pay for outpatient services provided on January 6, 2020, through January 7, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the heart (75571) 
provided on June 12, 2020. 
 
You asked the Plan to pay for a CT scan. You say that this should be covered because it showed some 
calcification. The Plan denied your request. The Plan says this was a screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a CT scan, was requested solely for screening purposes in the absence of signs, 
symptoms or disease. Medicare does not cover this test solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for a computed tomography (CT) scan of the heart (75571) provided on June 
12, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services and ECG provided on March 3, 
2020. 
 
You asked the Plan to pay for the critical care services and ECG. You say that you are appealing the hospital 
bill. The Plan denied your request. The Plan says you were under hospice at the time of this emergency room 
visit. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the critical care services and ECG provided on March 3, 
2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injections, 
chemotherapy administration, Granisetron Hydrochloride injection, Azacitidine injection, and Epoetin Alfa 
injection provided on May 12, 2020. 
 
You asked the Plan to pay for the therapeutic, prophylactic, or diagnostic injections, chemotherapy 
administration, Granisetron Hydrochloride injection, Azacitidine injection, and Epoetin Alfa injection. You say 
that hospice was terminated as of May 1, 2020. The Plan denied your request. The Plan says Original Medicare 
would be responsible for payment of all Medicare covered services related or unrelated to the enrollees 
terminal condition. 
 
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 May 1, 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 therapeutic, 
prophylactic, or diagnostic injections, chemotherapy administration, Granisetron Hydrochloride injection, 
Azacitidine injection, and Epoetin Alfa injection provided on May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe glucose blood test provided on June 10, 2020.You asked the Plan to waive the cost share forthe service provided. You say that the glucose monitoring was not necessary.The Plan denied your request. The Plan says the copay was processed 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 $10 copay for diagnostic lab services and tests. You have been asked to pay $3.28 for the lab services.Because the amount is less than your $10 copay, you were charged the lesser amount. The service fallwithin the outpatient diagnostic tests 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 cost share forthe glucose blood test provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiology services provided by a 
participating provider on May 22, 2020. 
 
You asked the Plan to waive the copayment for ECG monitoring. You say that you sent the monitor back after 
3 days. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient diagnostic tests/in-network/basic radiological services/specialist.  
 
You have been asked to pay a $50 copayment for ECG monitoring. Since ECG monitoring services were 
provided, the correct copayment has been applied. ECG monitoring falls within the outpatient diagnostic 
tests/in-network/basic radiological services/specialist benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for radiology services provided by a participating provider on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
May 15, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that medically necessary services were 
rendered in good faith. The Plan denied your request. The Plan says prior authorization must be obtained for 
non-emergent services rendered by an out-of-network provider. 
 
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 subsequent nursing facility care (99309) 
provided on May 15, 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 first intraoral periapical x-ray (D0220), two additional 
intraoral periapical x-rays (D0230 x2), bitewings (D0272), and panoramic x-ray (D0330) provided on June 18, 
2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays, bitewings, and panoramic x-ray. You say that 
these charges and the collection do not belong to you. The Plan denied your request. The Plan says your 
benefits for these services have been 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, intraoral periapical x-rays and 
bitewings are limited to 2 of either codes D0220, D0230, D0270, D0272, D0273, or D0274 per 1 calendar year. 
The record shows that you received a first intraoral periapical x-ray (D0220) on May 22, 2020, and June 1, 
2020, and your intraoral periapical x-rays and bitewings benefits have been exhausted. The contract also says 
that panoramic x-rays (D0330) are limited to 1 of either codes D0210 or D0330 per 3 calendar years. The 
record shows that you received a panoramic x-ray (D0330) on May 22, 2020, and your panoramic x-ray benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-
ray (D0220), two additional intraoral periapical x-rays (D0230 x2), bitewings (D0272), and panoramic x-ray 
(D0330) provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99201) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria has not been met. 
 
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 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99201) to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on June 2, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you don't know why the Plan didn't 
pay for anything. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient diagnostic tests/diagnostic radiology hospital.  
 
You have been asked to pay $131.35 which is less than your copayment amount of $250 for an ultrasound. An 
ultrasound falls within the outpatient diagnostic tests/diagnostic radiology hospital 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 an ultrasound provided by a participating provider on June 
2, 2020.