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 records received do not show that daily skilled services can only be provided 
on an inpatient basis in an IRF. The Plan states the records do not show a medical need for a move to an IRF 
level of care. The Plan states the enrollee can safely receive the services they need in the hospital setting. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of stroke and ataxia and is living at home with weakness and falls. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the documentation does support a need for physical and/or occupational therapy, there 
is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable 
expectation that this enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM). 
 
You asked the Plan to preapprove the CGM. You say that you require the device. The Plan denied your request. 
The Plan says you are requesting the CGM to use for monitoring purposes, not for therapeutic purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Specifically, the requested CGM device does not meet the definition 
of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided 
that the Plan does not have to preapprove a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
 
 
 
 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 May 19, 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 the services provided on November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869), for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is to treat the enrollee's lumbar spinal stenosis 
with neurogenic claudication. The Plan denied your request. The Plan says unproven and not medically 
necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
 
 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member has no skilled therapy or skilled nursing service needs. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81540) rendered by the out-of-
network (OON) provider on June 9, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (81540) rendered by the out-of-network (OON) provider on 
June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request is unable to be approved. 
 
The Plan must follow Medicare rules. The rules say that for each covered spinal region no more than four (4) 
diagnostic joint sessions will be reimbursed per rolling 12 months. 
 
The records show that previous injections were performed on June 16, 2021, July 26, 2021, August 16, 2021, 
and August 23, 2021. Based on this information, we decided that Medicare rules for coverage of the injections 
have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint 
injections for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive oral evaluation (CPT code D0150) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have pain on the right side of your 
mouth and need emergency service. The Plan denied your request. The Plan says this provider is not in-
network with the Plan's dental vendor. 
 
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 
comprehensive oral evaluation (CPT code D0150) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncotype testing (81519) provided on May 28, 2021, by an 
OON provider. 
 
You asked the Plan to pay for Oncotype testing. You say that this is a Medicare-covered service. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 Oncotype testing (81519) provided on May 28, 
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. The Plan 
denied your request. The Plan says these services exceed the maximum benefit allowance. 
 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, maxillary partial denture (D5213) and 
mandibular partial denture (D5226) are each limited to one per 60 months. The record shows that you received 
a partial maxillary denture and mandibular denture on April 16, 2018 and your maxillary and mandibular 
denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
maxillary partial denture (D5213) and a mandibular partial denture (D5226).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on June 18, 2021.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration because this service was billed appropriately. The Plan denied your request. The Plan says this claim was not billed with an appropriate place of service code.
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 99309 is subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. We find that CPT code 99309 is not supported in the record. Specifically, this claim was not billed with an appropriate place of service code for the services rendered. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 2 and 4.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says core build up is not listed as a covered 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 core build up are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 2 and 4.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy (CPT code 97535) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says there are in-network providers that can provide the services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve occupational therapy (CPT code 97535) to be provided by an out-of-network provider.
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 enrollee requires LTACH care. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for an LTACH admission. 
 
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 there is no documentation provided indicating medical necessity for the 
requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for shingles vaccination provided on January 29, 2020. 
 
You asked the Plan to pay for shingles vaccination. You say that you did everything you were asked to do by 
the Plan and this claim should be covered. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because this vaccination is not covered by Medicare Part B and should be covered by 
your Medicare Part D benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles 
vaccination. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to shingles 
vaccination. Therefore, we decided that the Plan does not have to pay for shingles vaccination provided on 
January 29, 2020.  
 
Benefits for shingles vaccination 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on 
March 13, 2021. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denied 
coverage for all cardiovascular risk assessment genomic screening panels. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary 
cardiovascular screening testing provided on March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit and treatment (CPT code(s): 77002 X 5, 
20610 X 5, 99204 X 1, 73564 X 1, 73580 X 1, 27369 X 1, Q9967 X 6) to be provided to the enrollee by an out-
of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says they have contracted providers that can do the services 
the enrollee needs. 
 
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 and treatment (CPT code(s): 77002 X 5, 20610 X 5, 99204 X 1, 73564 X 1, 73580 X 1, 27369 X 
1, Q9967 X 6) to be provided to the enrollee by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for x-rays and lymphatic drainage provided from May 14, 2021, to May 18, 2021.
You asked the Plan to pay for x-rays and lymphatic drainage provided by a chiropractor. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the services billed by your provider are not covered by Medicare when provided in a chiropractic setting.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. X-rays and lymphatic drainage are not covered in a chiropractic setting. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from May 14, 2021, to May 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the otolaryngology visit you had on June 
15, 2021. 
 
You asked the Plan to waive the copayment for the otolaryngology visit. You say that you just went for a 
hearing exam.  You stated that you did not see the doctor. The Plan denied your request. The Plan says you 
were charged this copayment correctly.  The Plan says that you were not charged a copayment for the hearing 
exam, but you were charged a copayment for the office visit. 
 
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 specialist visits.  
 
The medical records show that you did have a hearing exam on this date.  However, the audiologist referred 
you to an otolaryngologist.  You saw the otolaryngologist on June 15, 2021, for ringing in the ears. The records 
show that a full medical history and medication history was performed as well as a physical examination. You 
were assessed with a right ear drum perforation and were then scheduled for a hearing aid consultation. You 
have been asked to pay a $10 copayment for the otolaryngology visit. The otolaryngology visit falls within the 
specialist visits 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 otolaryngology visit 
you had on June 15, 2021.