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

 
We decided that the Plan does not have to pay for mobile X-ray services provided on July 13, 2020. 
 
You asked the Plan to pay for the mobile X-ray services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 mobile X-ray services provided on July 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 28, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid due the hospice revocation in 
May prior to the date of service. The Plan denied your request. The Plan says per the Medicare guidelines, 
when an enrollee revokes, claims for payment are still submitted to Original Medicare until the first day of the 
month following revocation. 
 
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hospice election has been revoked or terminated.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 18, 
2020. The services in question were provided before the end of that month on May 28, 2020. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee. This claim must 
submit to Original Medicare first.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant abutment and an implant abutment supported 
crown on tooth # 15. 
 
You asked the Plan to pre-approve an implant abutment and an implant abutment supported crown on tooth # 
15. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan 
says tooth # 15 is a posterior tooth. The supplemental dental plan does not cover implants or implant related 
services on posterior teeth. 
 
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. Tooth # 15 is a posterior tooth. The supplemental dental benefit does 
not cover implants or implant related services on posterior teeth. Only anterior teeth are considered for implant 
coverage. Therefore, we decided that the Plan does not have to pre-approve an implant abutment and an 
implant abutment supported crown on tooth # 15.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a 
normal neurological exam with no red flags such as absent or diminished reflexes. In the records provided, 
physical therapy (PT) has been ordered but not yet done. Absent a 6 week trial of conservative therapy 
including PT the medical necessity of an MRI of the lumbar spine has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the continuous glucose monitor and supplies.. You say that the Continuous 
Glucose Monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a continuous glucose monitor to be covered, 
the enrollee must be insulin-treated with multiple (three or more) daily injections of insulin. 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. The record does not show that the enrollee is treated with insulin 
injections three or more times daily. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor and supplies. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Suprascapular Nerve Blocks injections (64418). 
 
You asked the Plan to pre-approve the Suprascapular Nerve Blocks injections. The Plan denied your request. 
The Plan says this type of injection is considered experimental / investigational, and effectiveness has not been 
established for the treatment of types of pain including shoulder pain. 
 
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 Suprascapular Nerve Blocks 
injections. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the literature indicates that there are insufficient studies on 
the long term efficacy of this procedure or that it is superior to standard corticosteroid intra-articular injections 
which the enrollee has failed already. Additionally, the documentation does not reveal that the enrollee has 
attempted physical therapy for the shoulders which is recommended as a first line treatment by the American 
Academy of Orthopedic Surgeons (AAOS) for the enrollee's shoulder arthritis. 
 
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 Suprascapular Nerve Blocks injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Suprascapular Nerve Blocks injections (64418).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF 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 pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs but they do not need to be provided in a SNF 
setting or on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 4 additional PT visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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 4 additional PT 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 based on the available records the enrollee appears to have 
plateaued with therapy. Further therapy at this point beyond the approved 8 additional treatments does not 
appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rinvoq. 
 
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 Rinvoq.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 22 or more drug classes 
provided on June 3, 2020. 
 
You asked the Plan to pay for the definitive drug testing. You say that this was medically necessary testing that 
was time sensitive. The results of this testing were returned to the ordering physician within 24 hours. The Plan 
denied your request. The Plan says multiple requests were made for the progress note from the ordering 
physician, but no records were returned. As such, it cannot be confirmed that coverage criteria are met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to 
confirm that Medicare coverage criteria are met.  
 
In this case, despite requests, no medical records from the ordering physician were submitted. Without these 
records, it cannot be confirmed whether the testing provided was reasonable and necessary and that other 
coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the definitive 
drug testing of 22 or more drug classes provided on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on March 7, 2020 billed 
with code 99291. 
 
You asked the Plan to pay for the critical care services. You say that the records support that treatment for a 
critically ill patient was provided. The Plan denied your request. The Plan says the amount of time spent caring 
for the patient was not documented. As such, critical care services cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician's progress note(s) shall document 
the total time that critical care services were provided. 
 
In this case, the progress note does not document the time spent providing critical care services. As such, 
payment cannot be made for services billed with code 99291. Therefore, we decided that the Plan does not 
have to pay for the critical care services provided on March 7, 2020 billed with code 99291.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft and upper partial denture. 
 
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 the services are not covered. 
 
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 a 
bone replacement graft and upper partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve a partial upper denture and a partial lower denture. You say that the items 
are necessary. The Plan denied your request. The Plan says the benefit has 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. The Plan covers partial 
dentures once every 60 months. 
 
We looked at the file and Medicare rules. You received a partial upper denture and a partial lower denture on 
September 1, 2016. Based on this information, we decided that the Plan's rules for coverage of a partial upper 
denture and a partial lower denture have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a partial upper denture (D5211) and a partial lower denture (D5212).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after November 29, 
2020. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage of SNF 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy 
service needs. There are no identifiable skilled nursing service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care after November 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 27, 2020. 
 
You asked the Plan to pay for the laboratory 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 
laboratory 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 laboratory services provided on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
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 the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
October 25, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician 
services provided to the enrollee on October 25, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim should be submitted to Original Medicare. 
 
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 
physician services provided to the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the requested 10 
additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says that the 
requested 10 additional physical therapy visits are not medically necessary. 
 
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. Specifically, it is the plan's responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's 
failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the 10 additional physical therapy visits. A 
request for these records was made to the Plan with no response. Therefore, we decided that the Plan has to 
pre-approve 10 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services that you provided. 
 
You asked the Plan to pay for the physician's services. 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 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 physician's services that you provided.