Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transportation services.
You asked the Plan to pre-approve the transportation services. You say that this is the only way to get the
enrollee to her first post-operative appointment and should be necessary care and covered by the insurance
company. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport
services.
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we
decided that the Plan does not have to pre-approve the transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6242), sinus augmentation (D7951), custom
fabricated abutment (D6057), two endosteal implants (D6010 x2), and abutment supported retainer (D6071)
under your medical benefit.
You asked the Plan to pre-approve the pontic, sinus augmentation, custom fabricated abutment, two endosteal
implants, and abutment supported retainer under your medical benefit. You say that these services are
medically necessary. You also say that you would like these procedures covered under your medical insurance.
The Plan denied your request. The Plan says all of the requested codes are dental in nature and are not covered
under your medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6242), sinus
augmentation (D7951), custom fabricated abutment (D6057), two endosteal implants (D6010 x2), and
abutment supported retainer (D6071) under your medical benefit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung
Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT Lung Cancer screening. You say that the procedure 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 LDCT Lung Cancer screenings are covered for
enrollees ages 55-77.
We looked at the file and Medicare rules. The record shows the enrollee does not meet the age criteria for
coverage. Based on this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer
screening have not been met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose
Computed Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Latuda 40mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the
enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Latuda 40mg tablet
medication.
Benefits for this medication 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care services for wound care.
You asked the Plan to pre-approve home health care services for wound care. 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 home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health care services for wound
care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records
show that you are receiving wound care. The records indicate that your husband was performing wound care. It
is not clear why another trained caregiver is unable to perform the same wound care. The documentation
submitted is only for the May 20, 2020 date of service but you have been getting wound care for 22 weeks. The
documentation does not reveal that you are homebound therefore the request for home health skilled nursing
services cannot be considered medically necessary to effectively provide treatment, care, and/or services in
order to improve your condition, or to establish/perform a maintenance program to maintain your condition
and/or prevent deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health care services for wound care have not been met. Therefore, we
decided that the Plan does not have to pre-approve home health care services for wound care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are 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 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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical
status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional
multiple therapies, however your functional level does not require or indicate that this therapy must be in an
IRF with an intensive level program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance to be provided by an out of network
provider.
You asked the Plan to pre-approve an oral appliance. You say that you are seeking gap coverage. The Plan
denied your request. The Plan says the oral appliance is available in-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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an oral appliance to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on December 12, 2019 by an out-ofnetwork
provider.
You asked the Plan to pay for vision services. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 vision services provided on December 12, 2019 by
an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 78813) provided on November 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were
billed without an appropriate diagnosis code.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The plan indicates that the services in question were not billed with an
appropriate diagnosis code. The plan has not provided documentation showing that the billed diagnosis code is
inappropriate for the billed services. Without supporting documentation, the plan's denial cannot be
substantiated. Therefore, we decided that the Plan has to pay for the services (CPT 78813) provided on
November 1, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator
electrode array (63650)
You asked the Plan to pre-approve the implantation. You say that you would like reconsideration because this
is the best treatment option for the member. The Plan denied your request. The Plan says this service is not
medically reasonable and necessary.
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 implantation. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the member does not have an evidence based indication for this procedure. He has not had an
adequate trial of conservative therapy and never had any surgical intervention.
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 implantation have not been met. Therefore, we decided that the Plan does
not have to pre-approve a percutaneous implantation of neurostimulator electrode array (63650).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a spacer device.
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this
procedure is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to
support that this device is as safe and effective as the gold standard of decompression.
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 device. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the spacer is experimental and more research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the insertion of a spacer device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord (62380).
You asked the Plan to pre-approve the decompression. You say that you would like reconsideration because
this procedure is medically necessary. The Plan denied your request. The Plan says medical studies do not
show that this works better than traditional surgery.
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 decompression. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the procedure is experimental and not shown to be more effective than open
laminotomy Surgery.
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 decompression have not been met. Therefore, we decided that the Plan does
not have to pre-approve endoscopic decompression of spinal cord (62380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition solution; compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51
grams of protein - premix (B4189) and parenteral nutrition supply kit; premix, per day (B4220) provided to the
enrollee from November 15, 2019 through November 21, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met.
Healthcare Common Procedure Coding System (HCPCS) code B4189 (7 Units) remains not supported. The
documentation submitted did not include an itemized shipping/billing invoice, proof of delivery to indicate the
specific supplies for the billed date range of 11/15/2019- 11/21/2019. Therefore, the billed supply code cannot
be verified. It is noted that multiple attempts were made to contact the provider for additional information.
Healthcare Common Procedure Coding System (HCPCS) code B4220 (7 Units) remains not supported. The
documentation submitted did not include an itemized shipping/billing invoice, proof of delivery to indicate the
specific supplies for the billed date range of November 15, 2019 through November 21, 2019. Therefore, the
billed supply code cannot be verified. It is noted that multiple attempts were made to contact the provider for
additional information. Therefore, we decided that the Plan does not have to pay for parenteral nutrition
solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including
preparation, any strength, 10 to 51 grams of protein - premix (B4189) and parenteral nutrition supply kit;
premix, per day (B4220) provided to the enrollee from November 15, 2019 through November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on November 15, 2019.
You asked the Plan to pay for this service. You say that you are requesting reconsideration of the Plan's denial for payment as you chose this chiropractor because he was approved to accept the billing and rules. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for nursing facility care (99305) provided on September 4, 2019.
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim was billed by a non-physician practitioner who cannot bill directly for services rendered.
The Plan must follow Medicare rules. Medicare rules say that nurse practitioners may retrospectively bill for services when specific criteria are met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nursing facility care have been met. This is a nurse practitioner and therefore eligible to bill Medicare. Therefore, we decided that the Plan has to pay for nursing facility care (99305) provided on September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out of network medical services. You say that the medical records provided warrant the medical necessity of the service billed. The Plan denied your request. The Plan says the Hospital is an out of network provider and no prior authorization was requested before the services were rendered.
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 medical services provided on October 9, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance ride provided on July 30, 2019.
You asked the Plan to pay for the ambulance ride. You say that the patient was enrolled in hospice, however,
the ambulance transport was for something not related to the enrollee's hospice diagnosis. The Plan denied your
request. The Plan says the Medicare hospice benefits 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. 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. The record
shows proof of hospice election from July 13, 2019 to August 6, 2019. Therefore, we decided that the Plan
does not have to pay for the ambulance ride provided on July 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora sleep study provided by the provider on August 15, 2019.You asked the Plan to waive the copayment fora sleep study. You say that you disagree with the charges.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 $250 copayment for advanced radiology services. You have been asked to pay a $250 copayment for a sleep study. A sleep study falls 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 copayment fora sleep study provided the provider on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Pall Serene Power Lift Chair purchased on June 21, 2019. 
 
You asked the Plan to reimburse you for the seat lift mechanism. You say that because of your hip you need to be able to get up from a seated position with a power chair. The Plan denied your request. The Plan says you did not purchase from a Medicare certified supplier. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the Pall Serene Power Lift Chair purchased on June 21, 2019.