Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that it would be unsafe to send the enrollee home.The Plan denied your request. The Plan says the enrollee does not require close medical supervision, or complex rehab needs that can only be met in an IRF.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 topre-approve IRF care. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physicianevaluation.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Yupelri. 
 
You asked the Plan to pre-approve a tier exception for Yupelri. You say that you would like the plan to make a 
tier exception for this drug. The Plan denied your request. The Plan says tier exceptions are not covered for Part 
B medications. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Review of the file shows that you are 
requesting a tier exception for a Part B drug. Tier exceptions are only covered for Part D drugs. Based on this 
information, we decided that Medicare rules for coverage of a tier exception for Yupelri have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a tier exception for Yupelri.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's therapy needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate, including 
control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, 
cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) 
(CPT Code 0421T). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. You have requested coverage for the transurethral waterjet ablation 
of the prostate for the member. Medicare and the FDA have determined that the transurethral waterjet ablation 
of the prostate is a FDA Category B Investigational Device Exemption item. In order for Medicare and the 
member's plan to cover this, the member would need to be in a Medicare approved study. Currently, there are 
no facilities actively recruiting. Therefore, we decided that the Plan does not have to pre-approve transurethral 
waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, 
complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal 
urethrotomy are included when performed) (CPT Code 0421T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on June 30, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that your dental benefits show a $0 copayment for routine services. You also say that you should be reimbursed up to $1,500, whether the services areprovided in-network or OON.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that the total of $97.00 was applied correctly, and cost sharing is a contractual obligation that cannot be waived.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 Medicarecoverage, you are responsible for the difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on June 30, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis (K0606) provided May 17, 2020. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that please see the attached medical 
records along with the waiver of liability. The Plan denied your request. The Plan says submit required DME 
modifiers. 
 
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, procedure code K0606 was billed with either an invalid or missing modifier. Per April 2020 
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) procedure codes K0606 has a 
modifier RR and KF. The billing of modifier RR, KJ and KX are not eligible for payment. Based on this 
information, we decided that Medicare rules for coverage of the automatic external defibrillator have not been 
met. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator, with 
integrated electrocardiogram analysis (K0606) provided May 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown for tooth #19 provided on July 1, 2020. 
 
You asked the Plan to pay for the crown for tooth #19. You say that you have coverage for crowns. You say 
that the cost of the crown should be paid. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
for tooth #19 provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided  that the  Plandoes not haveto pre-approvea power seat elevation  system.You asked the  Planto pre-approvethe system.  You say  that the enrollee  appropriately  satisfies  the criteria  in this  case.The  Plandenied  your  request. The  Plansaysthis  is  not a covered benefit.The  Plan  must  follow  Medicare  rules.  The  rules  say that  for  equipment  to be covered,  it  must  primarily  serve  a medical  purpose.  The  item  at issue  in  this  appeal  does not serve  a purpose  that  is primarily  medical  in  nature.  This  item  is available  to the general  public  and would  be helpful  even  to those  who  are not  sick or injured.Therefore,  we decided  that the Plandoes not haveto pre-approvea power seat elevation  system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 30, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast tomosynthesis (77063) and screening 
mammography (77067) provided on June 8, 2020. 
 
You asked the Plan to pay for the breast tomosynthesis and screening mammography. You say that you would 
like reconsideration because multiple procedures were rendered on the same date of service. The Plan denied 
your request. The Plan says these services have already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the breast tomosynthesis and screening mammography have not been met. Specifically, the record 
shows that this is a duplicate claim. Therefore, we decided that the Plan does not have to pay for the breast 
tomosynthesis (77063) and screening mammography (77067) provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on December 19, 2019. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80061, 80053, 85052) provided on 
June 22, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 laboratory services (80061, 80053, 85052) 
provided on June 22, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482, 80307) provided on 
October 8, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you rely on the referring physician to 
obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by 
the facility or the provider; therefore, payment has been correctly denied. 
 
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 drug testing services (G0482, 80307) provided 
on October 8, 2019, 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 oral exam, cleaning, and fluoride provided on July 7, 
2020. 
 
You asked the Plan to pay for the dental services. You say that your dentist was in network. You say that now 
you pay him after you receive the services and then get reimbursed. You say that you were incorrectly charged 
the full amount. You say that you did not know he was no longer participating with the dental plan. You also 
say that you do not want to change dentists after seeing this one for so many years. The Plan denied your 
request. The Plan says the dental provider in this case is not a participating provider with the dental plan. The 
Plan says if you receive services from an dentist that does not participate with the dental plan, you will be 
responsible for the full cost of those services and no payment will be made. 
 
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 services you received are not 
payable when you receive them out of network. 
 
Therefore, we decided that the Plan does not have to pay for the oral exam, cleaning, and fluoride provided on 
July 7, 2020.
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 it is felt that IRF care is necessary for this enrollee. 
The Plan denied your request. The Plan says the enrollee is medically stable and does not require hospital-level 
care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for sepsis and wounds of the lower extremities. Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. 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 patient 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires visits at least three times per week, and 24 hour nursing for med trials.The Plan denied your request. The Plan says the enrollee does not meet the guidelines for IRF services. The Plan also says that the documentation indicates that the enrollee's needs can be safely met ina lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not requiretreatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer also found that there is no indication that the enrollee would be able to cooperate with skilled rehabilitation in an IRF, participating in rehab services 15 hours a week. The enrollee does not require the supervision of a physician with at least 3 visits weekly to regain or maintain her 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies provided. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order to support medical necessity for the supplies provided in 
this case. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the infusion supplies provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy (45378) 
performed on June 8, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you did not have any 
surgery. The Plan denied your request. The Plan says the correct copayment was 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 $325 
copayment for surgical service at an outpatient hospital facility. Your contract also says that if a doctor thinks it 
is necessary to perform a colonoscopy for medical reasons (e.g. due to the presence of symptoms), this is not 
considered a screening colonoscopy and outpatient surgery copayments will apply. 
 
You have been asked to pay a $325 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 
within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers" 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 diagnostic 
colonoscopy (45378) performed on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 13, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on January 13, 2020.