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

 
We decided that the Plan does not have to pre-approve dental services (D5820 and D5821). 
 
You asked the Plan to pre-approve the services. You say that this will assist you during the course of dental 
treatment. The Plan denied your request. The Plan says these services are not covered under your benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D5820 and D5821).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the meals rendered by the out-of-network 
(OON) providers on July 10, 2020. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by out of network 
providers, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to issue reimbursement care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The providers in this case are not network providers with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to issue reimbursement for these services. Additionally, the 
meal benefit is not covered for travel purposes. Therefore, we decided that the Plan does not have to issue 
reimbursement for the meals rendered by the out-of-network (OON) providers on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (CPT Code 
E0277) for the enrollee. You asked the Plan to pre-approve the DME. You say that the enrollee falls out of a 
regular bed every day and needs a hospital bed. The Plan denied your request. The Plan says the Medicare rules 
have not been met. 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. The records do 
not show the enrollee has any pressure ulcers. Therefore, we decided that the Plan does not have to pre-approve 
powered pressure-reducing air mattress (CPT Code E0277) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says needs can be met in a lower level of care, such as skilled nursing facility or 
inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided from October 14, 2020 to 
October 19, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the provider 
is not eligible to provide services under this policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements.  
 
We looked at the file and Medicare rules. The records do not show that acupuncture services were rendered by 
an eligible provider. Based on this information, we decided that the rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided from October 
14, 2020 to October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's ongoing care needs include intravenous antibiotics, surveillance 
laboratory studies, close fluid balance, glucose management, multiple wound can vacuum drain care, ostomy 
care, and therapy services. The documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on August 10, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the services were necessary. The Plan denied your 
request. The Plan says screening is 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 test at issue in this appeal, the x-ray, 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 chest x-
ray provided on August 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspiration remains experimental. More research is needed to show safety and efficacy. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the follow-up ophthalmology services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON care. You say that you have only ever gone to this doctor for your 
eye care and feel that the issue you are having should be evaluated by this provider. The Plan denied your 
request. The Plan says you can be seen in a timely manner by an in-network provider. There is no medical 
reason given that the OON is required. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 OON care. Our reviewer says that the requested OON medical care is 
not considered reasonable and necessary. Our physician reviewer found it is documented that the enrollee is a 
72-year-old woman who underwent cataract surgery on 11/18/19 and 12/16/19. The medical record dated 
5/7/20 documents the enrollee has diagnoses of pseudophakia and open angle glaucoma with borderline 
findings. The enrollee stated that her eye is not doing well and is bleeding. The documentation does not support 
that the out-of-network provider is medically reasonable and necessary for the enrollee in this case. 
 
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 OON care have not been met.  
 
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 the OON care.  
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve the follow-up ophthalmology services to be 
provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the physical therapy services provided from 
August 28, 2020, to September 6, 2020. 
 
You asked the Plan to waive the cost share for the services provided. You say that there should not have been a 
fee charged for services. The Plan denied your request. The Plan says the copays were applied 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 $40 
copay per day for outpatient rehab services.  
 
The file shows that you received physical therapy services on August 28, 2020, September 3, 4, and 6, 2020. 
You have been asked to pay a $40 copay per day for the services provided. The services fall within the 
outpatient rehab 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 you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the physical 
therapy services provided from August 28, 2020, to September 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on August 12, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care, per day (99221) provided on  
April 28, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that Original Medicare is responsible for 
payment of the services provided. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 28, 2020. The service in question was provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per 
day (99221) provided on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the psychotherapy (90833) 
rendered by the out of network (OON) provider on July 10, 2020 and August 11, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) and the psychotherapy (90833) rendered by the out of network 
(OON) provider on July 10, 2020 and August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is falling consistently, and in a lot of 
pain. The Plan denied your request. The Plan says the enrollee does not need close medical supervision, or a 
coordinated team approach to 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 physician reviewer found 
that the enrollee was admitted to the acute hospital for placement of a spinal cord stimulator and was 
discharged home. There is ongoing weakness, and there have been falls. Her medical conditions are stable. The 
complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the scaling and root planing. You say that the services are medically 
necessary. The Plan denied your request. The Plan says these services would exceed the plan maximum 
allowed amount of $1,500 per calendar year for Dental services. 
 
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, Dental services approved by the plan 
have already exhausted the enrollee's $1,500 maximum benefit. The enrollee is responsible for any cost in 
excess of $1,500. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing 
(D4341).
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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee can safely receive the services needed in another setting. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine fracture then was transferred to a skilled nursing facility where she received 
therapy services. She has now been discharged to her home and remains weak. The enrollee's medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that the 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (vedolizumab). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the member has not tried and failed the preferred step therapy drug(s): Stelara. The 
Plan states there is no indication the Plan's preferred drug(s) would likely be: less effective, and/or cause 
adverse effects for the member. 
 
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 the medication. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The 
enrollee is noted to have Crohn?s disease/IBD. A request has been made for Entyvio, treat the Crohn?s disease. 
The health plan requires that other medications be used. There is no evidence that the enrollee is allergic to or 
intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded 
to these other forms of medication.  There is no documentation as to why these other forms of medication 
would not be expected to be safe and effective for the enrollee. Therefore, the requested Entyvio is not shown 
to be currently medically necessary and reasonable. 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 medication have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (vedolizumab).