Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leg prosthesis to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a leg prosthesis. You say that you prefer to have this provider build your 
prosthesis. The Plan denied your request. The Plan says that a network gap does not exist. 
 
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 
a leg prosthesis to be provided 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 periodontal maintenance provided on June 18, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you asked if the service was covered 
before you had any treatments. You say that you were told everything was fully covered. The Plan denied your 
request. The Plan says your annual allowance has 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, you also have an annual allowance of 
$2,000. The Plan paid $2,000 toward your dental services received on January 17, 2020, and February 3, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says they are unable to approve the request. 
 
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 testing. Our reviewer says that the 
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is older than sixty and lacks a family history. The enrollee does not have bilateral breast 
cancer. The service is not reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve BRCA 1 and 2 testing for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Xolair injection (J2357) received on 
May 26, 2020. 
 
You asked the Plan to waive the coinsurance for a Xolair injection. You say that this service did not previously 
cost so much. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare-covered Part B drugs.  
 
You have been asked to pay $24.17, or 20% of the Plan-allowed amount of $120.85, for a Xolair injection. A 
Xolair injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for a Xolair injection (J2357) received on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional resin-based composites provided on May 
20, 2020. 
 
You asked the Plan to pay for the resin-based composites. You say that you were told your part of this payment 
would be $500, but you received a bill from the Plan for $1,012. The Plan denied your request. The Plan says 
your plan only covers two fillings per calendar year, which have already been authorized by the Plan. 
 
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, restorations are limited to two 
procedures per calendar year. The record shows that you received 4 resin-based composites on May 20, 2020, 2 
of which were covered by the Plan, and your restoration benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the two additional resin-based composites provided on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture provided on May 26, 2020. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you cancelled your insurance not 
knowing you would need this service. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pay for the 
mandibular partial denture provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-rays (D0330) provided on June 29, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are on a fixed income. You say that you pay 
for your coverage every month. You say that you needed these services so you can get dentures. You also say 
that there should not be a frequency limit for these services. The Plan denied your request. The Plan says 
comprehensive oral evaluations and panoramic x-rays are covered once every 3 plan years. The Plan says that 
the frequency limits for these services have been exceeded. 
 
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 and the services are listed as covered, 
the frequency limits for these services have been exceeded. The records shows that the Plan paid for these 
services that you received on January 8, 2020. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and panoramic x-rays (D0330) provided on June 29, 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 you need intensive therapy in order to go home and 
perform the daily activities you are used to. You say that IRF care is needed in order for you to return to your 
physical and active lifestyle, and in order to have a higher quality of life. The Plan denied your request. The 
Plan says the guidelines for coverage have not been met. The Plan says that the services needed can be 
provided in 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. 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 injuries received in a motor vehicle collision. He had surgical repair of lower leg fracture. He 
had exploratory laparotomy and repair of bladder rupture. Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program.  
 
The medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that 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: 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 the enrollee cannot be adequately care 
for in his current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current acute setting. 
 
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 physician 
reviewer found that the enrollee who was admitted to the current acute care hospital with redness and drainage 
to surgical site following recent post femoral bypass with graft and bilateral femoral artery endarterectomy. He 
was treated with antibiotics, debridement of wound, wound VAC, and other post-operative wound care. 
Surgery planned closure of the wound and removal of the wound VAC soon and an additional 3 weeks of 
antibiotics is planned. The enrollee appears to be requiring less than an additional 25 days of acute care 
services to complete his treatment, based on the recent notes. The enrollee does not require services at the 
LTACH that are not already available at the current setting. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of a complete maxillary denture (D5750), reline of 
a complete mandibular denture (D5751), and maintenance and cleaning of a maxillofacial prosthesis (D5993) 
provided on February 20, 2020. 
 
You asked the Plan to pay for the denture relines and maintenance and cleaning of a maxillofacial prosthesis. 
You say that you were given approval for your dentures to be fixed at an outside facility. The Plan denied your 
request. The Plan says these services are not covered benefits. 
 
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 reline 
of a complete maxillary denture (D5750), reline of a complete mandibular denture (D5751), and maintenance 
and cleaning of a maxillofacial prosthesis (D5993) provided on February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for doctor's appointments. The Plan denied your request. The Plan says that you have exceeded limits set in the 
subscriber agreement. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to provide routine transportation trips above the benefit maximum of sixty (60) 
routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a virtual colonoscopy. 
 
You asked the Plan to pre-approve a virtual colonoscopy. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that virtual colonoscopies are only covered for certain 
indications. 
 
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 a virtual colonoscopy. Our reviewer 
says that the documentation supports that the requested services are medically reasonable and necessary. Our 
physician reviewer found the enrollee has recurrent GI blood loss and concern for malignancy. In addition, the 
enrollee has ischemic heart disease and has concerns about anesthesia for colonoscopy. Virtual colonoscopy is 
indicated in this case as patient has risks, that are reasonable to assume, that makes her not wish to undergo 
anesthesia and colonoscopy. As this test is central to the enrollee's diagnosis, it is reasonable and indicated 
since there is a reasonable chance patient will have malignancy and the study will impact management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a virtual colonoscopy have been met. Therefore, we decided that the Plan has to 
pre-approve a virtual colonoscopy.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on June 15, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the infection came back and you 
couldn't find an available dentist. You say that you shouldn't have to pay $50. The Plan denied your request. 
The Plan says the service exceeds the frequency limitation in benefit plan. 
 
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, you also have a maximum benefit of 
one limited oral evaluation every plan year. The Plan paid for a limited oral evaluation on March 2, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation provided on June 15, 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 the enrollee was discharged from the hospital and is 
in need of therapy to recover. You say that the enrollee is currently receiving home health care, but is in need 
of 24 hour care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not 
been met. The Plan says that the enrollee could receive the care 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 acute encephalopathy and urinary tract infection. He was discharged to home on October 21, 
2020, and is requesting admission from home to inpatient rehabilitation because of ongoing weakness. The 
enrollee's medical problems are stable and there are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy but it does not 
support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for direct skilled nursing service of a registered nurse (RN) in 
the home health or hospice setting, each 15 minutes (G0299) provided April 2, 2019 to April 25, 2019. 
 
You asked the Plan to pay for direct skilled nursing service. You say that please see the attached nursing visit 
notes. Please review and reprocess claim accordingly. The Plan denied your request. The Plan says re-bill 
charges on Ub04 or 837I. 
 
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, we find that CPT code G0299 is not supported in the medical record. Specifically, according to 
Medicare Claims Processing Manual, Chapter 10-Home Health Agency Billing, claims are required to be billed 
on the Original Medicare form which is CMS-1450, also known as the UB-04. Based on this information, we 
decided that Medicare rules for coverage of direct skilled nursing service have not been met. Therefore, we 
decided that the Plan does not have to pay for direct skilled nursing service of a registered nurse (RN) in the 
home health or hospice setting, each 15 minutes (G0299) provided April 2, 2019 to April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 8, 2020 and August 7, 
2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with 
limited exceptions, you must use network providers to get your medical care and services. The only exceptions 
are emergencies, urgently needed services when the network is not available (generally, when you are out of 
the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers. 
 
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 did not pre-approve the 
physician's services. 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 physician's services provided on July 8, 2020 and August 7, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with urinalysis test (99214, 81003) provided 
on July 17, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with urinalysis test. 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 office visit with urinalysis test (99214, 81003) 
provided on July 17, 2019, by an out of network (OON) provider.