Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that the network provider is too far from your 
residence. The Plan denied your request. The Plan says the services are available from 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 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.  The Plan provider is located within an 
acceptable distance from your residence, per Medicare accessibility rules. 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 referral to an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional physical therapy services.You asked the Plan to pre-approvephysical therapy services. You say that the enrollee needs additional skilled intervention to maximize strength, balance, and gait.The Plan denied your request. The Plan saysthe enrollee's condition has not significantly improved.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.The file shows that 10 physical therapy visits were requested. The Plan has agreed to pre-approve 2 visits. 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 services. Our physician reviewer found that for debility post-stroke, physical therapy is generally accepted as specific and effective therapy. Goals include reducing post-stroke pain, restoring function, and educating regarding a home exercise program prior to transition towards a home program. In this case, there is no indication residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed not 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 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0220, D0140) provided January 14, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were an emergency and should be 
covered. The Plan denied your request. The Plan says the services are considered dental in nature. Insufficient 
medical records were provided to support payment and the enrollee has not purchased a dental plan. 
 
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 dental services (D0220, D0140) 
provided January 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT heart scan with 3D imaging. 
 
You asked the Plan to pre-approve a CT heart scan with 3D imaging. You say that the requested CT heart scan 
with 3D imaging is medically necessary. The Plan denied your request. The Plan says the requested CT heart 
scan with 3D imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT heart scan with 3D imaging. Our 
reviewer says that the requested CT heart scan with 3D imaging is not medically necessary. Our physician 
reviewer found based on the records provided the enrollee is with some coronary risk but no symptoms of chest 
pain or dyspnea. In this circumstance guidelines for evaluation and management of coronary risk have been 
established and do not include routine measurement of coronary calcium. Change in treatment based on 
screening coronary calcium scanning has not been shown to improve cardiac outcome incremental to that 
achievable based on standard risk factor profiling and basic lipid analysis. The requested CT heart scan with 
3D imaging is not medically reasonable and 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 a CT heart scan with 3D imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT heart scan with 3D imaging.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the echocardiogram, the duplex scan of 
lower extremities, and the duplex scan of extremity veins provided on February 4, 2020. 
 
You asked the Plan to waive the copayments for the echocardiogram, the duplex of lower extremities, and the 
duplex scan of extremity veins. You say that you should only have one copayment because the three tests were 
performed in the same office, same day, and the same facility. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $85 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay an $85 copayment for each of the radiological diagnostic tests. ($75 x 3 = $225). 
The echocardiogram, the duplex of lower extremities, and the duplex scan of extremity veins fall within the 
?Outpatient diagnostic tests and therapeutic services and supplies? benefit category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the echocardiogram, the duplex scan of lower extremities, 
and the duplex scan of extremity veins provided by on February 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be managed in a long-term care facility. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found your conditions are 
chronic. You have had extensive prior skilled nursing, and should be competent in disease education and 
management. Your needs are not a professional skilled nursing level. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 7, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. 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 the 
drug testing services provided on December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve dermatology services. You say that you would like approval to see this out-
of-network provider. The Plan denied your request. The Plan says there are in-network providers available to 
provide these services. 
 
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 
dermatology services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional six home health physical therapy (PT) visits (in addition to six approved).
You asked the Plan to pre-approve the additional home health PT visits. You say that it is felt that more care is needed. The Plan denied your request. The Plan says six more visits of the 12 requested were approved in order to finalize training in a home exercise program.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional home health PT visits. Our reviewer says that the requested number of PT visits are not medically reasonable and necessary. Our physician reviewer found the records do not show that skilled therapy services at the requested frequency are required to effectively provide treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration.
The patient was approved extensive prior therapy and should be able to transition to a HEP. The request for additional therapy beyond what was approved by the health plan is not 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 the additional home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional six home health physical therapy (PT) visits (in addition to six approved).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 
3, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you saw the doctor and 
were told there was nothing that could be done for six weeks. You say you should not be charged the 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for specialist visits.  
 
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls 
within the ?Physician/Practitioner services, including doctor?s office visits? benefit category. The medical 
record shows you were seen for a specialist office visit for trigger finger. 
 
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 specialist office visit provided on April 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and lens purchased on October 9, 2019 from a 
non-participating provider. 
 
You asked the Plan to pay for the frames and lens. You say that you went to the cheapest provider that you 
could find and believed that your specific plan election should cover the services. The Plan denied your 
request. The Plan says you do not have out-of-network benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
Review of the file show that you purchased the frames and lens on October 9, 2019 from a non-participating 
provider. Your EOC states, coverage under this vision care benefit is available only through supplemental 
vision 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. 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 frames and lens purchased on 
October 9, 2019 from a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovana. 
 
You asked the Plan to pre-approve Brovana. You say that the drug being requested is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements of coverage of the 
Brovana because prescriptions for Advair and Trelegy Ellipta are also being filled. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Brovana. Our reviewer says that 
Brovana is not medically reasonable and necessary. Our physician reviewer found the enrollee is already using 
Trelegy, which contains a LABA, and the plan is to continue the Trelegy while using Brovana. Dual treatment 
with two different LABAs runs the risk of adverse effects without proven benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Brovana.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have difficulty with walking and being able to prevent accidents. You say that you had a knee transplant and you believe that a bath chair would help you. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Fasenra pen. 
 
You asked the Plan to pre-approve Fasenra. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition under Medicare 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 a Fasenra pen.  
 
Benefits for Fasenra 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on April 
1, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that this was an emergency because 
you broke your front tooth, and you were in pain. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. The Plan also says that you are not enrolled in the 2020 Platinum 
Dental Rider Benefit. 
 
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 first 
intraoral periapical x-ray (D0220) provided on April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bike purchase. 
 
You asked the Plan to pre-approve the bike. You say that your fitness membership should apply to this 
purchase in lieu of a gym membership. The Plan denied your request. The Plan says the purchase of a bicycle 
to use while gyms are closed is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers $300 worth of 
gym membership benefits per calendar year. 
 
The Plan?s rules for coverage of gym benefits have not been met because a bike is not considered part of the 
benefit. Medicare specifically does not cover exercise equipment. Therefore, we decided that the Plan does not 
have to pre-approve a bike purchase.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ankle foot orthosis (L4396) provided on 
August 7, 2019. 
 
You asked the Plan to waive the coinsurance for the orthosis. You say that you were not advised by the doctor 
that you would have a copayment. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received an ankle foot orthosis (L4396) on August 7, 2019. You are asked to 
pay 20% coinsurance for the orthosis. Your EOC states, "enrollees must pay 20% coinsurance for Medicare-
covered prosthetic devices and related supplies. Devices (other than dental) that replace all or part of a body 
part or function. These include, but are not limited to: colostomy bags and supplies directly related to 
colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a 
surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or 
replacement of prosthetic devices." 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 ankle foot orthosis 
(L4396) provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve ophthalmology services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
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
ophthalmology services 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 pre-approve a prefabricated post and core in addition to crown 
(D2954). 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to crown. The Plan denied your 
request. The Plan says this service is not a covered benefit. 
 
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 a 
prefabricated post and core in addition to crown (D2954).