Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 requested IRF care is not considered medically reasonable and 
necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, 
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient was admitted for scheduled cervical fusion and removal of cervical 
nerve sheath tumor. Medical conditions are stable. There are no medical needs requiring inpatient admission. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ENTRESTO. 
 
You asked the Plan to pre-approve ENTRESTO. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 ENTRESTO.  
 
Benefits for ENTRESTO 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services provided on September 1, 2020. 
 
You asked the Plan to pay for the transportation services. You say that Medicare has expanded their list of 
covered destinations. The Plan denied your request. The Plan says that ambulance transport to or from an 
outpatient office is not a Medicare-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the list of allowable destinations for ambulance 
transports has expanded during the public health emergency. 
 
We looked at the file and Medicare rules. Based on the emergency ruling information, we decided that 
Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the ambulance 
transportation services provided on September 1, 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 vision services provided on June 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the claim was submitted with an authorization. 
The Plan denied your request. The Plan says prior authorization was not obtained as required. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the vision services provided on June 23, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two ultrasounds (76830, 76856) provided 
on August 14, 2020. 
 
You asked the Plan to waive the copayment for two ultrasounds. You say that you believed all copayments 
were being waived due to COVID-19. The Plan denied your request. The Plan says this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $115 
copayment for each Medicare-covered radiological diagnostic service, including ultrasounds.  
 
You have been asked to pay a $230 copayment for two ultrasounds ($115 copayment per diagnostic service x 2 
ultrasounds = $230 total). 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 two ultrasounds (76830, 
76856) provided on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on September 9, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not aware 
that there was a limit to this service of only one per year. You also say that you feel that full information should 
be provided to subscribers. The Plan denied your request. The Plan says this service exceeded the dental benefit 
frequency/limitation of one procedure per plan year. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on June 30, 2020, and your problem focused limited oral evaluation 
(D0140) had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation (D0140) provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 30, 2020, by an 
out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan and the services are not 
urgent. 
 
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 September 30, 
2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
congestive heart failure. Medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on September 15, 
2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges 
because you received the laboratory tests during an office visit. The Plan denied your request. The Plan says 
the claims were processed correctly, and you are being charged the correct 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 $10 
copayment for laboratory tests.  
 
You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests 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 
copayment for laboratory tests provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dentist for surgical 
removal of erupted tooth. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says you must use network dental providers to receive dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services when they are provided by a network dentist.  
 
The requested provider is not in the plan's dental network. Based on this information, we decided that the Plan's 
rules for coverage of the referral have not been met. Therefore, we decided that the Plan does not have to pre-
approve a referral to an out-of-network dentist for surgical removal of erupted tooth.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Retrobulbar injection services coded 67500 provided on 
July 20, 2020. 
 
You asked the Plan to pay for the Retrobulbar injection services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 67500 is Retrobulbar injection; medication (separate 
procedure, does not include supply of medication). 
 
We find that CPT code 67500 is not supported in the medical record. Specifically, this code was reported 
without a required anatomical modifier. the anatomic-specific modifiers LT (Left side), RT (Right side), and 50 
(Bilateral procedure) designate the area or part of the body on which the procedure is performed. These 
modifiers are required whenever they are appropriate. Based on this information, we decided that Medicare 
rules for coverage of the Retrobulbar injection services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Retrobulbar injection services coded 67500 provided on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that the enrollee has multiple risk factors. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee uses insulin three or more 
times per day. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid check, binaural provided on August 12, 2020. 
 
You asked the Plan to pay for the hearing aid check, binaural. You say that this same service was performed on 
May 23, 2017, and the service was covered. The Plan denied your request. The Plan says this service is not 
covered by Medicare and you did not use an 
in-network provider. 
 
The Plan must follow Medicare rules. Medicare does not pay for hearing aids or related services. The rules say 
that except for emergency and urgently needed services, plans are not required to make payments for any 
services received by enrollees that are not provided directly by the Plan or through arrangements made by the 
Plan. 
 
We looked at the file, Medicare's rules and the Plan's rules. The rules say that Medicare does not pay for 
hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids. The services at 
issue in this appeal were not provided in an emergency or urgent care situation. These services were not 
provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to 
pay for a hearing aid check, binaural provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare currently only has very limited coverage of CardioMEMS. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this circumstance therapy change based on data obtained from a CardioMEMS device has been 
demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met since the device should still be considered experimental or investigational. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS HF device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for open or surgical arthroscopic/endoscopic 
procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise specified (CPT Code 01830-QZ) 
provided on April 10, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include documentation of a start and stop time for 
the anesthesia administration; therefore, the billed service cannot be verified. 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 pay for the services. Our physician reviewer found the review has determined that 
Current Procedural Terminology (CPT) code 01830-QZ (108 unit) remains not supported. The documentation 
submitted did not include documentation of a start and stop time for the anesthesia administration; therefore, 
the billed service cannot be verified. The review has determined that the services are not supported in the 
medical records. 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 pay for anesthesia for open or surgical arthroscopic/endoscopic procedures on distal 
radius, distal ulna, wrist, or hand joints; not otherwise specified (CPT Code 01830-QZ) provided on April 10, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services. 
 
You asked the Plan to pre-approve the home health care services. You say that you have not been able to see 
your primary care physician because you are bed bound and cannot leave your house. You also say that you 
need help because you have several health issues. The Plan denied your request. The Plan says supporting 
clinical information was not provided to indicate that you meet Medicare criteria or the required physician's 
order for home health care services. 
 
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 home health care services. Our 
reviewer says that the request for home health services is not medically necessary. Our physician reviewer 
found the documentation does not support that you have been evaluated by a medical provider to assess your 
needs for home health care. Our reviewer also found that the documentation does not support that you require 
skilled nursing services or skilled rehab services to provide treatment that is medically necessary or to 
effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance 
program to maintain your condition and/or prevent 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 the home health care services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health care services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you received on October 6, 
2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $10 
copayment for Medicare-covered laboratory tests.  
 
Review of the file shows that you were provided lab services on October 6, 2020. You have been asked to pay 
a $10 copayment for the services. The services fall within the outpatient diagnostic 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 lab services you received on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on September 2, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the physician services. You say that the documentation supports the service. The 
Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the physician services provided on September 2, 2020 by an out of network 
provider.