Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 9 skilled nursing visits to be provided in the home.
You asked the Plan to pre-approve the skilled nursing visits. You say that you are appealing the denial of the skilled nursing visits. The Plan denied your request. The Plan says the additional skilled nursing visits are not considered reasonable and necessary for dressings of small or superficial wounds.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the skilled nursing visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. The requested home health services are not 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 the skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 9 skilled nursing visits to be provided in the home.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detections by nucleic acid for the Coronavirus (codes U0003 and U0005).
You asked the Plan to pay for the infectious agent detections. You say that this claim is not hospice related. You also say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 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 infectious agent detections by nucleic acid for the Coronavirus (codes U0003 and U0005).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pay for IRF care. You say that IRF care is necessary for you to return to your prior level of function. The Plan denied your request. The Plan says the criteria for an IRF are not met, and you can safely receive the services you need in a less intensive 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 pay for 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 14, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's
primary care physician did not refer these 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 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 lab work provided on April 14, 2021 by an out-ofnetwork
(OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on April 26,
2021.
You asked the Plan to pay for an abdominal ultrasound. You say that the enrollee had multiple exams. The Plan
denied your request. The Plan says this code is not separately payable.
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, we have confirmed that code 76705
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an abdominal ultrasound (76705) provided on April 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ECG (93010) and ED visit (99285) provided on January 23, 2021.
You asked the Plan to pay for the ECG and ED visit. You say that you have no record of receiving adjudication for this claim. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 ECG (93010) and ED visit (99285) provided on January 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair transportation services provided February 22,
2021.
You asked the Plan to pay for the transportation services. You say that this should be covered because the xrays
were part of your treatment to know what to do next. Nothing could be done at the healthcare center, so
you were transported to a hospital where they had an x-ray machine. The Plan denied your request. The Plan
says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport
services.
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided
that the Plan does not have to pay for the wheelchair transportation services provided February 22, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen system.
You asked the Plan to pre-approve a portable oxygen system. You say that the items are necessary. The Plan denied your request. The Plan says you received a home oxygen system previously and there is no indication that it is not working properly or not serving your needs within the home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a home oxygen system. A home oxygen system serves the same purpose as a portable oxygen system. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

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 ten (10) additional PT visits. 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 based on review of the available records, you do not meet Medicare coverage criteria for the requested continued services by a physical therapist with more visits for mechanical traction to treat back pain. Since beginning PT, you made good progress for shoulder treatment and back pain and at this stage skilled therapy is not warranted and you were given a home program for exercises. Mechanical traction is not a traditional and accepted treatment for chronic back pain. The documentation does not support the need for the requested additional therapy visits. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
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 was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec.
You asked the Plan to pre-approve Nurtec. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nurtec.
Benefits for Nurtec 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam image capture and interpretation (D0365) provided on April 13, 2021.
You asked the Plan to pay for the dental imaging service. You say that this service was necessary and should be covered. The Plan denied your request. The Plan says this service is not covered by your dental 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 pay for a cone beam image capture and interpretation (D0365) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine physical examination provided on April 9, 2021.
You asked the Plan to pay for routine physical examination. You say that these regular visits are imperative to
keeping track of your ongoing medical issues. The Plan denied your request. The Plan says the denial of
payment for this service is correct, because you already received a routine physical examination on January 6,
2021; therefore, the benefit was exhausted for this date of service.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover routine physical
checkups. The Plan has an annual routine physical exam benefit that goes beyond Medicare rules. For that
reason, the Plan's rules apply to this case. The Plan covers one annual routine physical examination per year.
We looked at the file and Medicare rules. You previously received a covered annual routine physical
examination on January 6, 2021; therefore, the routine physical benefit was exhausted for this date of service.
Based on this information, we decided that Medicare rules for coverage of routine physical examination have
not been met. Therefore, we decided that the Plan does not have to pay for a routine physical examination
provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July
17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 17,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 26, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for drug test. You say that you were not aware of the requirement of obtaining prior
authorization. The Plan denied your request. The Plan says the denial of payment for this testing is correct,
because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the
Plan.
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 drug testing provided on April 26, 2021 by an outof-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on March 9, 2021 and the core buildup and crown provided on March 10, 2021.
You asked the Plan to pay for the limited oral evaluation, intraoral x-ray, core buildup and crown. You say that you are entitled to 8 x-rays per year and 2 dental exams per year. You say that you want to know why you can't use your x-ray and exam benefit for this visit. The Plan denied your request. The Plan says the services you received are not covered by your supplemental Preventative Dental Coverage.
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, only preventive dental services are covered under this benefit. The services at issue are not considered preventive dental services and are not listed as covered benefits in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on March 9, 2021 and the core buildup and crown provided on March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on April 20, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you were not informed that you would owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for diagnostic radiology other than CT scans. You have been asked to pay a $295 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on April 20, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ibrance.
You asked the Plan to pre-approve Ibrance. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that effective January 1, 1994, Medicare Part B coverage
is extended to include oral anti-cancer drugs that are prescribed as anti-cancer chemotherapeutic agents
providing they have the same active ingredients and are used for the same indications as anti-cancer
chemotherapeutic agents which would be covered if they were not self-administered and they were furnished
incident to a physician's service as drugs and biologicals.
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 Ibrance. Our reviewer says that the
medication is medically necessary. Our physician reviewer found Palbociclib (Ibrance) is FDA approved for
the treatment of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative
advanced or metastatic breast cancer (in combination with an aromatase inhibitor) in postmenopausal females
or in adult males as initial endocrine-based therapy. This enrollee meets these criteria and the treatment is
reasonable and 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 Ibrance have been met. Therefore, we decided that the Plan has to pre-approve
Ibrance.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the
enrollee's condition has improved, and she is no longer a threat.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
Continued inpatient services from September 8, 2021, forward were requested. 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 continued services. Our physician reviewer found that the
enrollee was admitted to the acute inpatient psychiatric hospitalization with Schizoaffective Disorder Bipolar
Type and Unspecified Personality Disorder. She presented with disruptive behavior.
Based upon review the records provided it was not expected this enrollee would improve in a reasonable period
of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any
auditory or visual hallucinations. She was compliant with treatment while not showing any acute threats to
safety. It does 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 she did not have
dangerousness to herself or others.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued inpatient psychiatric services.