Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent nursing facility visit (99308, 1123F, 3288F) provided 
on May 13, 2020, and May 20, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that the provider is not 
recognized as payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a NP may be covered under Part 
B if the conditions are met. 
 
We looked at the file and Medicare rules. In this case, the Plan denied the services at issue because the provider 
is not recognized as payable by Medicare. However, Medicare rules are clear that a NP may bill and get paid 
directly. There was no documentation provided to show that this provider is not recognized by/eligible to 
participate in Medicare. The Plan denial is not substantiated. Therefore, we decided that the Plan has to pay for 
the subsequent nursing facility visit (99308, 1123F, 3288F) provided on May 13, 2020, and May 20, 2020.  
 
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 pay for the medical services provided on April 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 April 22, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two removals of residual tooth roots. 
 
You asked the Plan to pre-approve the removals of residual tooth roots. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's 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, 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 two 
removals of residual tooth roots.
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 needs aggressive vent 
weaning, and daily physician intervention. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate care at the current acute care 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 physician 
reviewer found that the enrollee was admitted to acute care inpatient hospital with chest pain. The enrollee is 
hemodynamically unstable. The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage services coded 10061 provided on 
March 11, 2020. 
 
You asked the Plan to pay for the incision and drainage services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple. 
 
We find that CPT code 10061 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that incision and drainage of abscess complicated or multiple was performed. Based on 
this information, we decided that Medicare rules for coverage of the incision and drainage services have not 
been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage services coded 
10061 provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the naturopathic services you received on May 11, 2020, and 
May 28, 2020. 
 
You asked the Plan to pay for the services. You say that you thought this was covered. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for the naturopathic services you received on May 11, 2020, and May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve complete maxillary dentures for the enrollee. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the dentist must send more x-rays. 
 
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. The Plan covers the dentures 
when the services are medically necessary and reasonable. 
 
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 dentures. Our reviewer says that the 
requested dentures are medically reasonable and necessary. Our physician reviewer found the reason for the 
denial was a lack of documentation. A review of the records indicate that the panorex radiograph shows 
edentulous maxillary and mandibular arches. This would substantiate the need for a maxillary denture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dentures have been met. Therefore, we decided that the Plan has to pre-
approve complete maxillary dentures for the enrollee.  
 
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: 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric tricycle.

You asked the Plan to pre-approve an electric tricycle with gears. You say that you need an electric tricycle for therapy on your knee joints. The Plan denied your request. The Plan says an electric tricycle is primarily used for a nonmedical purpose and does not meet the definition of durable medical equipment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Home exercise/ physical therapy equipment that can be obtained without a prescription is considered to be an over the counter supply, is not considered DME, and is therefore ineligible for coverage. Therefore, we decided that the Plan does not have to pre-approve an electric tricycle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a foam rubber mattress (E0272). 
 
You asked the Plan to pre-approve the foam rubber mattress. You say that you would like reconsideration 
because the member requires a special mattress due to pain from a motor vehicle accident. The Plan denied 
your request. The Plan says the mattress is not covered because the member does not have a hospital bed. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also say that a foam rubber mattress will be covered for a beneficiary owned 
hospital bed. 
 
We looked at your request, the file and rules. Based on this information we have determined that Medicare 
criteria for coverage of a foam rubber mattress have not been met. Specifically, the record does not indicate 
that the member has a hospital bed. Therefore, we decided that the Plan does not have to pre-approve a foam 
rubber mattress (E0272).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve robotic surgery for non-rheumatic mitral (valve)
prolapse to be provided by the out-of-network provider.

You asked the Plan to pre-approve the robotic surgery for non-rheumatic mitral (valve) prolapse. You say that
the enrollee needs a complex mitral valve repair due to eccentric mitral regurgitation and bileaflet mitral valve
prolapse. You say that the enrollee is a candidate for a minimally invasive complex repair that can potentially
be performed via robotic approach which will in turn shorten her hospital stay. The Plan denied your request.
The Plan says the enrollee must receive care from in-network providers with the exception of emergency or
urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization
from the plan. These services are 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve robotic
surgery for non-rheumatic mitral (valve) prolapse to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 4, 2019.

You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for 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 pay for the dental services provided on September 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27245) provided February 11, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service was performed by a Registered Nurse surgical assistant. This type of provider is not eligible for separate reimbursement for this type of procedure.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (27245) provided February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor for the 
enrollee. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria 
for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three 
or more times a day. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) (73221). 
 
You asked the Plan to pre-approve the MRI. You say that you are requesting an appeal. Please review. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee reports non-traumatic shoulder pain since July 2020. Physical examination on 
9/1/20 notes a normal physical examination. A plain film radiograph on 7/29/20 notes findings suggestive of 
calcific tendinosis of the rotator cuff. An MRI was ordered to evaluate for calcified tendonitis and rotator cuff 
tear.  There is no documentation of conservative treatment or plan of care pending study results. Without the 
support of the documentation, medical necessity cannot be determined. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that you are unable to climb the stairs at your home. The 
Plan denied your request. The Plan says a stair lift is not primary used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report only (93010) provided June 12, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that please reconsider claim with the attached 
medical record and process for payment. The Plan denied your request. The Plan says the records show that 
this service was previously approved/paid. 
 
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, the records show that the plan previously paid for the appealed services on check dated July 2, 
2020. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have 
not been met. Therefore, we decided that the Plan does not have to pay for electrocardiogram, routine ECG 
with at least 12-leads; interpretation and report only (93010) provided June 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 12, 2020 to April 9, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 March 12, 2020 
to April 9, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for continued SNF services after November 12, 2019. 
 
You asked the Plan to pay for SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says that rules for SNF care have not been met. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before November 12, 2019. The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for continued SNF services after November 12, 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.