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

 
We decided that the Plan has to pre-approve computed tomography (CT) colonography screening for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the evidence on benefits for colorectal cancer screening are minimal. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 services. Our reviewer says that the 
requested screening is medically reasonable and necessary. Our physician reviewer found the enrollee has 
constipation and left lower quadrant pain, so the requested CT colonography is not ordered as a screening tool. 
Also, her colon on her last direct colonoscopy was noted to be extremely redundant meaning the likelihood of a 
successful direct colonoscopy would be very unlikely. The combination of age, symptoms and comorbidities in 
a symptomatic patient means the requested CT colonography would likely be the best tool available for this 
enrollee. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) colonography screening 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracentesis (32555) provided on January 12, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 9, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the thoracentesis 
(32555) provided on January 12, 2021.
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 an LTACH is the enrollee's best chance 
at recovery, and his care cannot be provided at a lower level of care. The Plan denied your request. The Plan 
says your request for approval of an admission to an LTACH does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Our physician reviewer also found that transfer to 
an LTACH is not medically necessary as it would not be clinically advantageous as the patient is not yet stable 
enough. 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee from January 2, 
2020, to January 20, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 20, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for radiology services provided to the enrollee from January 2, 2020, to January 
20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient mental health visit you had 
on September 14, 2021. 
 
You asked the Plan to waive the copayment for the outpatient mental health visit. You say that you were 
scheduled for a 30-minute session but were billed for a 1-hour session.  You believe you should only be 
charged $12.50 for this visit. The Plan denied your request. The Plan says you were charged this copayment 
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 $25 
copayment per visit for individual outpatient mental health sessions.  
 
 
 
 
 You have been asked to pay a $25 copayment per visit for the outpatient mental health visit. This copayment 
applies regardless of the length of your visit. 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 
outpatient mental health visit you had on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that services were provided to the enrollee so the 
claim should be paid. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers with no approved authorization. Also, the services provided was not urgent or 
emergent. 
 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 had network providers 
available who could have provided 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 laboratory services provided on June 28, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on July 5, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that that you have out-of-network benefits for hearing 
benefits and the Plan should reimburse you $500 for the hearing aid purchase. The Plan denied your request. 
The Plan says the Plan's hearing vendor is the exclusive vendor for hearing services for the 2021 benefit year. 
Hearing services are covered in or out of network if they are coordinated through the Plan's vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained from the Plans contracted hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not obtained from the 
Plans contracted hearing provider. Based on this information, we decided that the Plan's rules for coverage of 
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids 
provided on July 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested scan. The Plan denied your request. The Plan says medical 
necessity has not been established. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 We looked at the file and the Medicare rules. The records do not show that the enrollee had a smoking history 
of at least 30 pack-years or has quit within the last 15 years. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a low dose computed tomography (LDCT) scan for lung cancer screening.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is 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 considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14-Day Sensor from March 25, 2022, 
forward. 
 
You asked the Plan to pre-approve the items. You say that the enrollee is on is on Metformin and insulin MPH. 
The Plan denied your request. The Plan says the enrollee is not on three (3) injections of insulin and adjusting 
their insulin doses based on their blood glucose readings. The Plan states Medicare only covers continuous 
glucose monitors (CGMs) for individuals who are intensely managing their diabetes by adjusting their insulin 
dose based on the blood glucose results frequently during the day. The Plan states they understand that the 
enrollee has a meter from their previous insurance, which was provided beyond what Medicare allows. The 
Plan states since this is the enrollee's current method for checking their blood sugar, they will allow a one-
month supply for the enrollee to obtain a standard meter to measure their blood glucose. The Plan states the 
authorization was approved for one-month supply of Freestyle Libre 14-Day Sensor, and the authorization is 
valid from February 24, 2022, through March 24, 2022. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 items. Our physician reviewer 
found the record indicates that the enrollee has diabetes and is treated with twice daily insulin that is not 
adjusted by the beneficiary. The elements of the coverage rule are not satisfied. The requested service is not 
recommended. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Libre 14-Day Sensor from March 25, 2022, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from 
March 2, 2022, forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that this care remains 
medically necessary. The Plan denied your request. The Plan says the criteria for continued inpatient 
psychiatric care have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 continuation of inpatient psychiatric 
care. Our reviewer says that the continuation of inpatient psychiatric care is not medically reasonable and 
necessary. Our physician reviewer found this 59-year-old male was involuntarily admitted to the acute inpatient 
psychiatric hospital on February 23, 2022, with paranoid schizophrenia. Based upon review the records 
provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in 
question as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and 
no aggressive behaviors. You were compliant and cooperative with treatment. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, 
hallucinations or aggressive behaviors. The Plan's denial of continued inpatient psychiatric services appears 
appropriate. 
 
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 continuation of inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from March 2, 
2022, forward.
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 recently had a fall and are very weak. You also 
say that wound care is still needed as well as physical therapy. The Plan denied your request. The Plan says the 
IRF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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. Our reviewer found 
that specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our physician reviewer also found that 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), additional periapical x-
ray (D0230), and bitewing x-rays (D0274) provided on October 31, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says 1 set of bitewings are covered per plan years. The Plan says that the frequency 
limit has been exceeded. The Plan also says that periapical x-rays are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and bitewing x-rays are listed as 
covered, the frequency limit of 1 set per plan year has been exceeded.  The record shows that the Plan paid for bitewing x-rays that you received on February 4, 2021. Additionally, 
periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the initial periapical x-ray (D0220), additional periapical x-ray (D0230), and bitewing x-rays 
(D0274) provided on October 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine 
(72131). 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the lumbar spine. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found that the record does not include a neurologic examination nor has conservative 
nonpharmacologic treatment, such as physical therapy, been performed. 
 
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 scan of the lumbar spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine (72131).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual heavy duty wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is meant for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a manual heavy duty wheelchair.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on June 12, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim was recouped. 
You also say that a reason for the recoupment was not provided. The Plan denied your request. The Plan says 
the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B 
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan 
also says it is the providers responsibility to verify the enrollees coverage before rendering services and to 
know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on June 12, 
2021.