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

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on May 
29, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code L0648 (1 Unit) remains 
not supported. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that lab testing 
generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific 
medical problem. 
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for durable medical 
equipment provided to the enrollee on May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee is scheduled for a knee 
arthroplasty. She has a history of insomnia, migraines and fibromyalgia. The records do not support any 
clinical rationale for an inpatient admission for the planned surgery. There is no reasonable expectation that the 
enrollee will require at least two midnights of inpatient care for the planned procedure. The inpatient level of 
care is therefore not reasonable or medically necessary. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan does not have 
to pre-approve an inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a routine eye examination provided on April 6, 
2020. 
 
You asked the Plan to reimburse you for the routine eye examination. The Plan denied your request. The Plan 
says you must receive the eye examination from a preferred provider with the Plan's vision network that 
provides the supplemental benefit for your plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a Plan preferred provider. 
 
We looked at the file and the Plan's rules. The file shows that the provider at issue in this case is not a Plan 
preferred provider. Based on this information, we decided that the Plan's rules for coverage of the routine eye 
examination have not been met. Therefore, we decided that the Plan does not have to reimburse you for a 
routine eye examination provided on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 2, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159 and 80173. 
 
You asked the Plan to pay for several lab services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the documentation submitted did not support that the denied codes were performed 
with blood sampling.  Blood specimen collection is by venipuncture; however, the lab requisition states a urine 
specimen was collected; therefore, the billed service cannot be verified. It is noted multiple attempts were made 
to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be paid due to an issue 
with the type of specimen reported. Medicare billing criteria are not met. Therefore, we decided that the Plan 
does not have to pay for lab services provided to the enrollee on April 2, 2020 and billed under codes 80157, 
80177, 80201, 80162, 80159 and 80173.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) provided 
on June 20, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not wish to utilize 
ambulance services. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $100 
copayment for ambulance services.  
 
You have been asked to pay a $100 copayment for the ambulance services. The services at issue fall within the 
ambulance 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 copayment for the ambulance 
services (A0429) provided on June 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bioness functional electrical stimulator (E0770, 
E1399). 
 
You asked the Plan to pre-approve a Bioness functional electrical stimulator. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for the use of NMES/FES is limited to 
SCI patients for walking. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee has a spinal cord injury. 
Based on this information, we decided that Medicare rules for coverage of a Bioness functional electrical 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Bioness 
functional electrical stimulator (E0770, E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab service provided to the enrollee, 
and billed under code 80307. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Current Procedural Terminology (CPT) code 80307 (1 Unit) remains not supported. The 
documentation submitted did not include a valid physician order/lab requisition or medical records (signed by 
the ordering physician); therefore, the billed code cannot be verified. It is noted multiple attempts were made to 
obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and physician documentation. In this case, the 
records provided do not support the services billed. Medicare rules for coverage of this service have not been 
met. Therefore, we decided that the Plan does not have to pay for lab service provided to the enrollee, and billed 
under code 80307.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 6, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 items/services at issue in this appeal. The Plan 
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for lab services provided to the 
enrollee on January 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that the physical therapist 
recommends 1 to 2 visits per week for 4 weeks. The Plan denied your request. The Plan says additional visits 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally 
accepted as specific and effective therapy for your condition. You have had prior therapy for this condition and 
it does not appear that your functional level requires the unique skills of a professional therapist to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or 
under the supervision of a therapist. You have been participating in a home exercise program. The specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain your current condition or to prevent or slow further 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 additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that the core build up is necessary. The Plan 
denied your request. The Plan says core build up is not listed as a covered service. The Plan also says if a 
dental item or service is not listed in the benefit chart then it 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. The Customer Handbook specifically says that resin and titanium 
crowns, ? crowns, pin retention, crown repair post and core, and core build up are excluded from coverage. 
Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral 
periapical x-ray provided on June 29, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you were told that this provider was 
in-network, and the services should be covered in full. The Plan denied your request. The Plan says the benefits 
for these services have been satisfied and the frequency limitation has 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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received an additional intraoral periapical x-ray on 
April 27, 2020, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on June 
29, 2020.  
 
Your complaint about the treatment of the provider and the misinformation you were given by the Plan is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 8, 2018. 
 
You asked the Plan to pay for the services. You say that you filed the claim timely but it was submitted to the 
wrong insurance company. The Plan denied your request. The Plan says the claim was not received within the 
timeframe of the Medicare guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until June 26, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on November 8, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 8, 2018. 
 
You asked the Plan to pay for the services. You say that you filed the claim timely but it was submitted to the 
wrong insurance company. The Plan denied your request. The Plan says the claim was not received within the 
timeframe of the Medicare guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until June 26, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on October 8, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies. 
 
You asked the Plan to pay for incontinence supplies. You say that on this date of service the enrollee was 
eligible for coverage of these supplies. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivelle-Dot for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vivelle-Dot for the 
enrollee.  
 
Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on April 21, 2020 and billed under codes 80157, 80177, 80201, 80162, 80159 and 80173.You asked the Plan to pay forthese services. You say that this claim should be paid.The Plan denied your request. The Plan says thedocumentation submitted did not support that this testing was performed with blood sampling.  Blood specimen collection is by venipuncture and the lab requisition does not state the specimen; therefore, the billed service cannot be verified. Of note, the submitted blood/serum requisition did not contain the billed test. It is noted multiple attempts were made to obtain additional information from the provider.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due to an issue with the type of specimen used. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on April 21, 2020 and billed under codes 80157, 80177, 80201, 80162, 80159 and 80173.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 6. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs a crown for tooth # 6. 
The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says 
if a dental item or service is not listed in the benefit chart or listed with NC, then it 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 pre-approve core 
build up (D2950) for tooth # 6.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXiidra eye drops for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are notamong the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveXiidra eye drops for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is not stable for transfer. 
 
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. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he/she is currently receiving care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH 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 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 for the enrollee.
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 needs rehab. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 
October 26, 2020 with pneumonia, bacteremia, and acute kidney injury. The physical therapy notes show that 
he needs minimal assist for rolling and sitting up and is walking 65 feet with assistance and a rolling walker. 
He does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require 15 hours per week of rehabilitative services and regular physician evaluation. 
 
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.