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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 the enrollee has been treated at an 
observational level of care and has remained medically stable. The enrollee is ready for discharge from the 
hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The 
enrollee is medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; 
complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute 
exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and she 
can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 
medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aftercare following a bone marrow transplant. 
 
You asked the Plan to pre-approve aftercare following a bone marrow transplant. 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 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 aftercare following a bone marrow 
transplant. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found hematopoietic stem cell transplantation (HSCT) has 
shown promise in uncontrolled trials of patients with progressive forms of multiple sclerosis (MS). Larger 
controlled trials are awaited to evaluate the risk/benefit ratio of autologous HSCT for the treatment of MS. 
Enrollment is still open for multiple trials evaluated HSCT. It is not yet a standard of care. The service is not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aftercare following a bone marrow transplant have not been met. Therefore, we 
decided that the Plan does not have to pre-approve aftercare following a bone marrow transplant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased June 11, 2020, from an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eyeglasses. You say that you would like this claim reprocessed and your 
allowance applied. The Plan denied your request. The Plan says the provider you purchased the eyeglasses 
from is an OON provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you purchased eyeglasses from the Plan's contracted vision 
vendor. 
 
 
 
 
 
We looked at the file and the Plan's rules. The file indicates that you purchased these eyeglasses from an OON 
provider and not from the Plan's contracted vision vendor. Based on this information, we decided that the 
Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pay for the eyeglasses purchased June 11, 2020, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray 
(D0330) provided on August 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had an oral exam. You say that you did not 
have a choice of x-ray. You say that you were in a lot of pain. You say that you cannot afford to pay this bill. 
You also say that you feel you should not have to pay for this service as the dentist office made decisions for 
you. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. 
The Plan says the panoramic x-ray is not listed as a covered service either. The Plan also says that the enrollee 
did not contact the Plan to verify benefits or provider eligibility. 
 
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 pay for the 
limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work and an ultrasound provided on July 10, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for lab work and an ultrasound. You say that you are in-network and do not need 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
member's primary care physician. The Plan says that the rendering physician is out-of-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab work and an ultrasound provided on July 10, 
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for laboratory tests provided from August 19, 
2020, to September 21, 2020. 
 
You asked the Plan to waive the copayments for laboratory tests. You say that you disagree with the charges 
because the labs should be included in the office visits. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 $10 
copayment for lab services. 
 
You received laboratory tests from August 19, 2020, to September 21, 2020, for a total of 3 services. 
Therefore, you are responsible to pay a $10 copayment per each service. The total amount you owe is: $30.   
 
You have been asked to pay the total copayment amount of $30 for laboratory tests. Laboratory tests fall within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for laboratory tests provided from August 19, 2020, to September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external infusion pump. 
 
You asked the Plan to pre-approve an external infusion pump. You say that the requested external infusion 
pump is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested external infusion pump. 
 
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 an external infusion pump. Our 
reviewer says that the enrollee does not meet criteria for the requested external infusion pump. Our physician 
reviewer found as there is no c-peptide level documented, we cannot say that the enrollee meets LCD criteria. 
This enrollee has pancreatic diabetes mellitus and would likely do very well with the proposed tandem CIQ 
pump;  however, in order to qualify for the pump per the criteria provided; we would need to see a low c-
peptide. 
 
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 external infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an external infusion pump.
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 you need to go to rehab to help you be more 
mobile. The Plan denied your request. The Plan says that your medical records indicate that you have no skilled 
nursing needs. 
 
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 you 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 skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mandibular partial denture and preventive procedure provided on October 6, 2020.

You asked the Plan to pay more for the mandibular partial denture and preventive procedure. You say that you feel that this claim should be paid. The Plan denied your request. The Plan says the calendar year maximum had been met.

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 combined allowance for supplemental preventive and comprehensive services every year. The contract clearly states that you are responsible for any amount over and above the allowance amount. The Plan paid a total $2,000 allowance for dental services during the 2020 Plan year, and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay more for the mandibular partial denture and preventive procedure provided on October 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora duplex scan of extremity veins (93970) provided on September 15, 2020.You asked the Plan to pay fora duplex scan of extremity veins. You say that the billed diagnoses are supported.The Plan denied your request. The Plan says this was not billed with the correct bilateral diagnosis.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.We find that the billing of this claim is not supported in the record. Specifically, this claim was billed with diagnosis codes I83.811 and I83.812, indicating right and left laterality. There is a more appropriate bilateral code for this diagnosis. Based on this information, we decided that Medicare rules for coverage of a duplex scan of extremity veins have not been met.Therefore, we decided that the Plan does not have to pay fora duplex scan of extremity veins (93970) provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate mandibular denture, five extractions, and non-intravenous conscious sedation provided on September 17, 2020.

You asked the Plan to pay for the immediate mandibular denture, extractions, and non-intravenous conscious sedation. You say that these services were covered under your 2020 plan coverage. The Plan denied your request. The Plan says these 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. The record shows that you opted out of the optional supplemental dental insurance during enrollment, and only had the Mandatory Supplemental Dental Benefits. Therefore, we decided that the Plan does not have to pay for the immediate mandibular denture, five extractions, and non-intravenous conscious sedation provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided on August 13, 2019.

You asked the Plan to pay for the inpatient hospital care. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the claim was untimely.

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 inpatient hospital care was not filed until September 18, 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 inpatient hospital care provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided on June 26, 2019.

You asked the Plan to pay for the inpatient hospital care. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the claim was untimely.

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 inpatient hospital care was not filed until September 16, 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 inpatient hospital care provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the amniotic cell membrane joint injection (incorrectly 
coded as 99499-Unlisted evaluation and management service/correct code Q4174) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the services. You say that you cannot walk without the injection. The Plan 
denied your request. The Plan says very little clinical information was received about your illness. The Plan 
states additional information was requested but not received. The Plan states this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature published in the English language. 
The Plan states the pending scientific assessment of the technique has been completed and its efficacy has been 
established they cannot approve. 
 
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. 
 
No medical records were provided to verify the medical necessity of the request. Furthermore, this provider is 
out-of-network and there are in-network providers that can be used. 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 the amniotic cell membrane joint injection 
(incorrectly coded as 99499-Unlisted evaluation and management service/correct code Q4174) to be provided 
by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and extractions to be 
provided by an oral surgeon. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation and extractions. You say that these 
services are medically necessary. You also say that you cannot afford to pay to see an oral surgeon. The Plan 
denied your request. The Plan says these services are not covered benefits because your contract specifically 
stipulates that dental services must be performed by an in-network general dentist. 
 
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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation and extractions to be provided by an 
oral surgeon.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says that that the services you require do not require daily inpatient skilled 
nursing and/or therapy services. 
 
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 that 
SNF care is medically reasonable and necessary. You were reportedly hospitalized then admitted to a SNF for 
treatment of cellulitis, weakness and CoViD-19. Records from these facilities have not been submitted for 
review. Therefore, it is unclear what rehabilitation services were provided to you while at these facilities, where 
you appear to have been on isolation/quarantine. There is no documentation to show that you had reached a 
plateau in function/new functional baseline while at these facilities. It seems reasonable to provide you with a 
documented trial of daily skilled therapy following your acute illness. Daily skilled services do appear to be 
required to establish a maintenance program and/or to prevent deterioration of your condition. Your care needs, 
as a practical matter, cannot be provided at a lower level of care. Our physician reviewer found that your 
condition meets 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 care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS implanted device, implantable 
hemodynamic monitors (33289) implantable wireless pulmonary artery pressure sensor (C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the enrollee will benefit greatly from 
this procedure and implant. Her quality of life and well-being are greatly impacted by chronic heart failure and 
repeat hospitalizations that come with it. The Plan denied your request. The Plan says this device is still being 
studied to determine if it is safe and effective. The enrollee is not in an approved clinical trial therefore, this is 
not covered by the plan. 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. Based on this information, we decided that Medicare rules for 
coverage of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CardioMEMS implanted device, implantable hemodynamic monitors (33289) implantable 
wireless pulmonary artery pressure sensor (C2624).