Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 24 one-way 
transportation trips per year. The Plan says that you have used all 24 one-way transportation for the 2020 
benefit year and additional trips will not be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #14.  
 
You asked the Plan to pre-approve core buildup (D2950). You say that the remaining tooth around the cavity is 
weak and prone to fracture. You say that this is also to restore the shape, size, strength and approve appearance. 
The Plan denied your request. The Plan says the 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 core 
buildup (D2950) for tooth #14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty walker with seat attachment (E0147, 
E0156). 
 
You asked the Plan to pre-approve the walker. You say that the walker is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that heavy duty walkers are covered when 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 walker. Our reviewer says that the 
heavy duty walker is not medically necessary. Our physician reviewer found there is no documentation that the 
requested heavy duty walker with seat attachment is medically necessary. There is no documentation in the 
provided records that the patient has problems finishing one or more mobility-related activities of daily living 
in the home (such as going to the bathroom, feeding, dressing, grooming, and bathing) or that the patient is 
unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use 
of one hand. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy duty walker with seat attachment (E0147, E0156).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. You do not require the services on an inpatient basis, in a skilled nursing 
facility setting. Services in a long-term care facility on a part time basis or in the home with home health 
services appears appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is diagnosed with Diffuse 
Large B Cell lymphoma of intrathoracic lymph nodes. The delivery of greater than 20 fractions of radiation in 
the metastatic setting seems outside of the standard of care based on National Comprehensive Cancer Network 
(NCCN) guidelines. The case file does not document the need for going outside of the standard of care. The 
services are not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 
81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 
81406) provided on March 26, 2020. 
 
You asked the Plan to pay for Guardant360 testing. You say that this is an established, medically necessary 
test. The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say to report a CGP service, test 
providers should use CPT code 81479. 
 
We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 
81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406 are not supported in the medical 
record. Specifically, the Guardant360 tests are considered CGP services and should be reported with 81479. 
Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been 
met.  
 
 
 
Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 
81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 
81404, 81405, 81406) provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 22, 2020. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed 
codes 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 a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on April 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a progressive lens provided on May 19, 2020. 
 
You asked the Plan to pay for vision hardware. You say that you were advised that the Plan pays for vision 
hardware both in-network and out-of-network, so you should have received the $100 benefit coverage for 
eyeglasses. The Plan denied your request. The Plan says the denial of payment for this item is correct, as the 
Plan's supplemental vision benefits only include direct member reimbursement for out-of-network providers so 
the provider cannot be paid directly. 
 
 
 
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 offers coverage of routine vision care and hardware obtained from out-of-network 
providers, however when using an out-of-network provider the enrollee is responsible for submitting a claim 
form with itemized receipt for reimbursement. 
 
We looked at the file and the Plan's rules. The enrollee is responsible for submitting a claim form with itemized 
receipt to the Plan for reimbursement. Based on this information, we decided that the Plan's rules for coverage 
of vision hardware have not been met. Therefore, we decided that the Plan does not have to pay for a 
progressive lens provided on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision hardware provided on July 8, 2020. 
 
You asked the Plan to pay for the routine vision hardware. You say that you would like the plan to reconsider 
their denial The Plan denied your request. The Plan says the amount billed exceeds your benefit limit. 
 
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 eyewear up to $220 per calendar year. 
 
We looked at the file and the Plan's rules. The plan covers up to $220 for eyewear. Review of the file shows 
that the total amount for the eyewear was $327. The plan paid the covered $220 toward this amount. Therefore, 
you are being asked to pay the remaining $107. Based on this information, we decided that the Plan's rules for 
coverage of the eye exam and the routine vision hardware have not been met. Therefore, we decided that the 
Plan does not have to pay for the routine vision hardware provided on July 8, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE) with Doppler. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has exertional dyspnea 
concerning for a cardiac cause but a normal cardiovascular and pulmonary physical exam, a recent normal 
nuclear stress test and a prior echo more than four years ago that reported mild atrial enlargement and mild 
valvular regurgitation. In this circumstance of new symptoms concerning for a cardiac cause, a repeat echo 
more than four years after the prior exam to assess for progressive valve regurgitation is reasonable, 
appropriate and considered standard accepted practice in the medical community. Current guidelines also 
consider a repeat echocardiogram appropriate in this setting. 
 
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 has to pre-
approve a transthoracic echocardiogram (TTE) with Doppler.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitamin D hydroxy (82306) provided on May 14, 2020. 
 
You asked the Plan to pay for the vitamin D hydroxy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the services are not authorized because code 
82306 is not a Medicare benefit for the diagnoses listed on the claim and is done for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Procedures should be reported with the CPT code that describes the services performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vitamin D hydroxy have not been met. Per Medicare's LCA, the diagnosis codes listed on the 
claim are not appropriate for the CPT code billed. Therefore, we decided that the Plan does not have to pay for 
a vitamin D hydroxy (82306) provided on May 14, 2020.
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 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 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 medically necessary. Our physician reviewer found the enrollee is 
currently undergoing treatment at an acute care hospital (ACH) for complications following hip surgery. The 
enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 20, 2020. 
 
You asked the Plan to pay for drug tests. You say that you have attached documentation showing a detailed 
listing of the specific drug classes covered under the ordered testing. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because the documentation submitted does not include 
a signed physician order or laboratory requisition for the billed tests. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on February 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Massage Therapy services. 
 
You asked the Plan to pre-approve Massage Therapy. You say that the massage therapy services are medically 
necessary. The Plan denied your request. The Plan says massage therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve Massage Therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need acute 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 
requested IRF care is not medically necessary. Our physician reviewer found the submitted records show that 
you were admitted to the hospital for a planned shunt replacement procedure. On October 11, 2020 you walked 
150 feet with a front wheeled walker and assistance. The physician progress note dated October 14, 2020 states 
you are medically stable. 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 may benefit from 
further therapy but do not require an intensive therapy program in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durvalumab. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found Durvalumab is FDA approved for the 
treatment of unresectable stage III non-small cell lung cancer (NSCLC) in adults whose disease has not 
progressed following concurrent platinum-based chemotherapy and radiation therapy. There is no 
documentation that the enrollee received radiation therapy or documentation of disease that has not progressed. 
The service is 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durvalumab.
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 the enrollee is a fall risk and requires this 
equipment for her health and safety. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on June 8, 2020. 
 
You asked the Plan to waive the copayment for dermatology services. You say that you were told these 
copayments were waived until the end of the year, The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $45 copayment for dermatology services. Dermatology services fall within the 
physician/practitioner services/in-network/specialist 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 a specialist office visit provided by a participating provider on June 8, 2020.  
 
We note your complaint about being told copayments were waived until the end of the year. Your complaint is 
a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.