Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you 
had at your otolaryngologist's office on May 26, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you already paid your $5 copayment 
so you shouldn't owe any more. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The plan says that because the allowed amount for the CT scan ($124.05) is less than your 
copayment obligation, you are responsible for the full 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 $150 
copayment for diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the diagnostic and 
nuclear medicine radiological services benefit category. Your Evidence of Coverage clearly states that you pay 
this copayment in addition to your specialist office visit copayment. 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 the computed tomography (CT) scan you had at your otolaryngologist's office on May 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial and subsequent hospital care provided. 
 
You asked the Plan to pay for the practitioner services. You say that the enrollee was not in hospice on the 
dates of service. The Plan denied your request. The Plan says The Medicare hospice benefit, through fee-for-
service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending 
physician services and all care unrelated to the terminal illness until the first day of the month following the 
month in which hospice was revoked or discharged. 
 
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 . 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 initial and subsequent 
hospital care provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Aimovig Autoinjector (C9399). 
 
You asked the Plan to pre-approve the Aimovig Autoinjector. You say that you would like reconsideration 
because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered 
for the member's condition under Medicare Part B. 
 
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 the Aimovig Autoinjector 
(C9399).  
 
Benefits for the Aimovig Autoinjector 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 6 and 7. 
 
You asked the Plan to pre-approve the dental services. You say that teeth # 6 and 7 have been filled multiple 
times over the last 10 years. You say that one the old filling and decay is removed there will be less than 50% 
healthy too structure remaining for both teeth. You also say that the crowns will allow you to meet the current 
standard of care. The Plan denied your request. The Plan says crowns are covered once per tooth every 5 plan 
years. The Plan also says that the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 crown per 
tooth every 5 plan years has been reached. Therefore, we decided that the Plan does not have to pre-approve 
crowns (D2740) for teeth # 6 and 7.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz tablet. 
 
You asked the Plan to pre-approve Xeljanz tablet. You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Xeljanz tablet.  
 
Benefits for Xeljanz tablet 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for evaluation and management of a 
spinal mass and renal mass. Medical problems are stable. There are no identified problems that need inpatient 
medical management. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-care/home management training services and the 
therapeutic activities provided on June 11, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the self-care/home management training services and the therapeutic activities. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services provided are not a covered benefit. 
 
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 self-care/home management training services 
and the therapeutic activities provided on June 11, 2020, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical 
history of hypertension, hypothyroidism and a meningioma who presented to the acute hospital on 10/26/2020 
with cognitive decline, gait difficulties and bladder issues. He was treated in the hospital with placement of a 
ventriculoperitoneal shunt for hydrocephalus. He is unsteady with gait and is working with physical and 
occupational therapy. He is walking 100 feet with a rolling walker with stand-by assistance and is stand-by 
 
 
assist for transfers and contact guard assist for activities of daily living. He is reported to be medically stable 
for discharge. 
 
Based on the medical records provided there is no documentation that the enrollee requires skilled nursing or 
skilled therapy services in a SNF. Daily skilled services are not required. This enrollee does not require the 
services on 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided from April 5, 2020, to April 
30 2020. 
 
You asked the Plan to pay for home infusion services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 S9342 is Home therapy; enteral nutrition via pump; 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment (enteral formula and nursing visits coded separately), per diem. 
 
We find that CPT code S9342 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare 
uses another code for reporting of, and payment for, these services. Based on this information, we decided that 
Medicare rules for coverage of home infusion services have not been met. Therefore, we decided that the Plan 
does not have to pay for home infusion services provided from April 5, 2020, to April 30 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 22, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing is used to determine the best therapy 
option for late-stage cancer. The Plan denied your request. The Plan says coverage of comprehensive genomic 
profile testing is limited to one test per specimen. 
 
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 provided testing was not billed per Medicare guidelines. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aripiprazole Tablet. 
 
You asked the Plan to pre-approve Aripiprazole Tablet. You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Aripiprazole Tablet.  
 
Benefits for Aripiprazole Tablet 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 waive the copayment for the office visits provided from March 2, 
2020, to June 11, 2020. 
 
You asked the Plan to waive the copayment for the office visits. You say that you disagree with the copayment 
amounts owed. The Plan denied your request. The Plan says the claim has been processed correctly per the 
enrollee's plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that you must pay 
a $45 copayment for physician/practitioner services.  
 
The enrollee has been asked to pay a $45 copayment for the specialist office visits. This provider that the 
enrollee received the office visits from is considered a Urology Specialist and is not the enrollees primary care 
physician. The office visits fall within the specialist physician/practitioner 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 the enrollee enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the office visits provided from March 2, 2020, 
to June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultralightweight wheelchair with anti-tipping device, 
pneumatic propulsion tires, detachable armrests and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that please consider reversing the denial decision 
for a customized wheelchair. Additional clinical information is attached to prove medical necessity.  
 The Plan denied your request. The Plan says Medicare does not cover wheelchairs in a nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve ultralightweight wheelchair with anti-tipping device, pneumatic 
propulsion tires, detachable armrests and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on January 17, 2019. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this claim was received past the allowed 12 month 
time-frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until May 27, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the office visit (99215) provided on January 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 21, 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 services are not covered. 
 
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 laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
does not state the specimen collected. Based on this information, we decided that Medicare rules for coverage 
of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of oral bisphosphonates AND Zoledronic acid is required before alternatives can 
be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record shows a trial of oral bisphosphonates 
(Aledronate) but not Zoledronic Acid.  The record does not show that the Plan preferred drugs would be unsafe 
or ineffective. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for fainting episode and was 
diagnosed with acute on chronic respiratory failure, acute congestive heart failure, cardiac ischemia and 
pneumonia. Medical problems are stable. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. 
  
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit you had with your 
urologist on June 4, 2020. 
 
You asked the Plan to waive the copayment for the telehealth visit with a specialist. You say that since this was 
a telephone call and not an office visit, there should be no copayment. The Plan denied your request. The Plan 
says you were charged this copayment 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 $50 
copayment for specialist visits, including telehealth services.  
 
You have been asked to pay a $50 copayment for the telehealth visit with a specialist. The Evidence of 
Coverage clearly states that this copayment applies to telehealth services in addition to in-office visits. 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 the telehealth visit you had with your urologist on June 4, 
2020.