Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy sessions to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that you can only walk very short distances. 
The Plan denied your request. The Plan says they have approved 2 of the requested 12 additional sessions. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 occupational therapy. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the documentation does not reveal that the enrollee requires 
the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can 
be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. 12 additional occupational therapy sessions 
have been requested. The Plan has approved 2 of these sessions, and 10 sessions have been denied. Based on 
this information, we decided that Medicare rules for coverage of occupational therapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve additional occupational therapy sessions to be 
provided by a participating provider.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for neck pain after a fall 
and was discharged home. There is ongoing pain and weakness. The enrollees medical problems are stable. 
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 patient has a need for physical and/or occupational therapy, there is no documentation of 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. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative (emergency) treatment of dental pain (D9110) 
provided on November 17, 2021. 
 
You asked the Plan to pay for palliative (emergency) treatment. You say that you were in a lot of pain and this 
treatment was medically necessary. The Plan denied your request. The Plan says the requested service is not 
listed as a covered benefit with your Plan. The Plan also says you did not select the additional dental coverage 
which would have covered the requested service. 
 
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 palliative 
(emergency) treatment of dental pain (D9110) provided on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you were seeing the out-of-network 
provider prior to switching insurances and you thought you would be able to see the same provider. The Plan 
denied your request. The Plan says the out-of-network neurologist stated to his office to relay to the health plan 
that the member can safely be transitioned at this time for care. An approved authorization for an in-network 
provider that is accepting new patients. 
 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided on April 29, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel have not been met. Specifically, this claim was billed using individual 
gene CPT codes. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel provided 
on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 19, 2021, to November 20, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not be 
charged since you were not placed in a room. 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 $395 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were admitted to the hospital as an inpatient from November 19, 2021, to November 
20, 2021, but there is no copayment for the discharge date.  Therefore, you have been asked to pay $395 for the first day of inpatient hospital care. The inpatient hospital 
care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from November 19, 2021, to November 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided the Plan does not have to pay for the vaccine provided on October 18, 2021.
You asked the Plan to pay for a measles, mumps, and rubella vaccine. You say that this vaccine should be covered by the Plan. The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B and should be submitted to your Medicare Part D carrier.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a measles, mumps, and rubella vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to a measles, mumps, and rubella vaccine. Therefore, we decided that the Plan does not have to pay for a measles, mumps, and rubella vaccine provided on October 18, 2021.
Benefits for a measles, mumps, and rubella vaccine 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of aqueous drainage device (0376T) provided 
on October 28, 2020. 
 
You asked the Plan to pay for the insertion of aqueous drainage device (0376T). You say that the attached 
operative notes should be reviewed and CPT code 0376T processed for payment. The Plan denied your request. 
The Plan says the medical records submitted don't include documentation of an additional device insertion of 
anterior segment aqueous drainage device. 
 
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 0376T is insertion of anterior segment aqueous drainage 
device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device 
insertion (List separately in addition to code for primary procedure).  We asked our coder 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 insertion of aqueous drainage device (0376T). Our 
reviewer says that the documentation does not support the insertion of an additional aqueous drainage device. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the insertion of aqueous drainage device (0376T) have not been met. Therefore, 
we decided that the Plan does not have to pay for the insertion of aqueous drainage device (0376T) provided on 
October 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve imaging services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the imaging services. You say that you are requesting reconsideration to 
provide services to the enrollee. The Plan denied your request. The Plan says there is an in-network provider 
that is within 7 miles from the enrollee's residence that provides the same quality of service. Also, the 
documentation received did not indicate that there is an emergent or urgent medical condition that the enrollee 
would need to see an out-of-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 
imaging services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and foot orthosis (L3170) 
provided on September 3, 2021. 
 
You asked the Plan to pay for the ankle foot orthosis and foot orthosis. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules state that ankle-foot orthoses are covered for ambulatory 
beneficiaries with weakness or deformity of the foot and ankle. 
 
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 ankle foot orthosis. Our reviewer says 
that the enrollee did not meet criteria for the provided ankle-foot orthosis (L1971) on September 3, 2021. Our 
physician reviewer found the enrollee was diagnosed with pain in the right foot/ankle. The case file does not 
contain documentation of physical examination or imaging of the foot and/or ankle. The documentation does 
not support that the enrollee had weakness or deformity of the foot and ankle, which required stabilization for 
medical reasons. 
 
Medicare rules also state that supportive devices for the feet (such as orthotics) are only covered for patients 
with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records 
show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
 
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 ankle foot orthosis and foot orthosis have not been met. Therefore, we 
decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and foot orthosis (L3170) 
provided on September 3, 2021.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 you received oral medications, had stable vital 
signs, lungs were clear, and you tolerated an oral diet. You were at a supervision to contact guard assist level 
for functional mobility including gait to 250 feet with a rolling walker. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 2, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you have a tooth that needs to be 
extracted, but due to medical issues, the extraction had to be postponed. You also say you had an oral exam 
done because of problems with an adjacent tooth to the one that needs extraction, they were concerned damage 
and decay were affecting the adjacent tooth. The Plan denied your request. The Plan says the requested services 
was denied due to frequency limitations of your dental plan. The Plan also says you were not eligible for 
another oral exam on the date of service. 
 
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 two limited 
oral evaluations per calendar year. 
 
We looked at the file and Medicare rules. The records show you had a limited oral evaluation on January 27, 
2021, and May 13, 2021; therefore, you have exhausted your maximum benefit for this service. Based on this 
information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 2, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity cellulitis and sepsis. Your medical problems are stable. 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 you have a 
need for physical and/or occupational therapy, there is no documentation of 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. Our physician reviewer found 
that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you do not have reliable transportation and the 
out-of-network doctor is within walking distance. The Plan denied your request. The Plan says the provider is 
out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
the office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that your incontinence started getting worse. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277) and 
total electric hospital bed (E1399). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a group 2 support surface is not medically necessary as the documentation does not reveal that the 
enrollee has failed use of an appropriate group 1 support surface. The documentation does not reveal large or 
multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure 
ulcer on the trunk or pelvis within the past 60 days. The criteria for the E0277 have not been met per Local 
Coverage Determination (LCD) L33642: Pressure Reducing Support Surfaces - Group 2. 
 
We looked at this physician's review, the file, and Medicare rules. Our doctor found that the requested mattress 
is not medically reasonable or necessary. The total electric hospital bed is never covered. 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 a powered pressure-reducing air mattress (E0277) and total 
electric hospital bed (E1399).