Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing kits purchased on January 28, 2022. 
 
You asked the Plan to pay for the COVID-19 testing kits. You say that there was a sign in the store saying 
insurance would cover two at home COVID-19 tests. The Plan denied your request. The Plan says people with 
Medicare will not be eligible to be reimbursed for COVID-19 tests purchased before April 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan.  
 
We looked at the file and Medicare rules. Over the counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Therefore, we decided that 
the Plan does not have to pay for the COVID-19 testing kits purchased on January 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from  
January 20, 2022, through January 28, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that the inpatient services were 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.  
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 pay for inpatient psychiatric hospital services. Our 
reviewer says that inpatient psychiatric hospital services provided from January 20, 2022, through  
January 28, 2022 are not medically necessary. Our physician reviewer found that based upon review of the 
records provided it was not expected this enrollee would improve in a reasonable period of time as she did not 
have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive 
behaviors. 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 as she did not have dangerousness to self or others. This 
enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others 
and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was 
taking place. It did not appear that the services were reasonably expected to improve the enrollees condition or 
for the purpose of diagnosis. Based upon review the records provided for the admission of this enrollee does 
not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to 
herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with 
treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient psychiatric hospital services provided from January 20, 2022, 
through January 28, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer 750MG/15ML solution (CPT code J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from your prescriber that shows you have tried one of the 
preferred drugs and it has not worked, or that you have medical reasons that prevent you from using one of 
them. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found there is no indication that you have tried and failed the required drug(s). Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer 750MG/15ML solution (CPT code J1439).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough medical evidence about this procedure. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture with electrical stimulation (97813 and 97814) 
provided from December 20, 2021, through December 29, 2021. 
 
You asked the Plan to pay for acupuncture services. You say that the enrollees condition is a covered 
condition and acupuncture is a covered procedure within the Plans policy. The Plan denied your request. The 
Plan says the denial of payment for acupuncture treatment was processed correctly.  
 The Plan says the rules and guidance for covered acupuncture services state that only certain provider types are 
authorized to provide acupuncture treatments. Auxiliary personnel, such as a licensed acupuncturist, must be 
supervised by a physician, physician assistant (PA), or nurse practitioner (NP)/clinical nurse specialist (CNS). 
The Plan found that this provider does not meet these requirements.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services were furnished by a non-covered 
provider type. A licensed acupuncturist must be supervised by a physician, PA, or NP/CNS for the services to 
qualify for coverage. Therefore, we decided that the Plan does not have to pay for acupuncture with electrical 
stimulation (97813 and 97814) provided from December 20, 2021, through December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the durable medical equipment (DME) is 
medically necessary. The Plan denied your request. The Plan says your doctor has prescribed a ventilator to 
help your breathing at various times of the day (night and day) because of your lung disease and Medicare does 
not cover ventilators used in this way. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. You have severe COPD. However, there is no 
evidence of chronic carbon dioxide (CO2) retention on an arterial blood gas (ABG) done as an outpatient while 
stable. If you do have chronic CO2 retention, BiPAP can be used to provide the average volume-assured 
pressure support (AVAPS) mode. Medicare does not cover a home ventilator when used as BiPAP. The denial 
is upheld.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
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. The Plan denied your request. The Plan says you can safely 
receive 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. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program.  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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings of all four 
quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that you would like this service to be 
approved for coverage. The Plan denied your request. The Plan says you are not covered for these benefits 
under your medical benefits, and you currently do not have comprehensive dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. You are not currently enrolled in the optional supplemental dental 
benefits. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root 
planings of all four quadrants.
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 enrollee will require frequent routine lab work, 
monitoring, drain care and daily physician oversight. You say that the enrollee fulfills the requirements for IRF 
level of care and treatment in a lower level of care could lead to an unfavorable outcome. The Plan denied your 
request. The Plan says the enrollee can safely receive services 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. Our 
physician reviewer found that the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you have limited support at home and are 
unable to return home safely at this time. The Plan denied your request. The Plan says the SNF services you are 
requesting do not meet the requirements for approval. 
 
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 the SNF services. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Skilled Nursing Facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue exam services (88305-TC) provided on August 3, 2021. 
 
You asked the Plan to pay for tissue exam services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment cannot be made for the technical 
component of the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that only the hospital may bill for the technical component (TC) of an independent laboratory pathology service provided to an inpatient or outpatient. 
 
We looked at the file and Medicare rules. Specifically, the documentation shows the enrollee was an outpatient 
on the date of service. No payment will be made to the independent laboratory for the technical component of 
the billed service. Based on this information, we decided that Medicare rules for coverage of tissue exam 
services have not been met. Therefore, we decided that the Plan does not have to pay for tissue exam services 
(88305-TC) provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request would exceed the three-scan limit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
requested PET scan is not medically necessary. Our physician reviewer found the enrollee has had 3 prior PET 
scans. Further evaluation can be done with computed tomography scans. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you cannot take care of yourself and need 
someone to help you walk and shower. The Plan denied your request. The Plan says the criteria for admission 
to a SNF have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided on January 31, 2022.

You asked the Plan to pay for a limited oral evaluation - problem focused. You say that your dentist felt the only way to determined which course of action you needed, was for you to get an endodontic evaluation with pulp vitality testing. You also say that your dentist recommended this dentist, who was also an in-network provider. The Plan denied your request. The Plan says this service is a covered benefit, but the enrollee has exceeded limits set in the subscriber agreement, and per the member's 2022 Evidence of Coverage the plan has limited dental benefits and these services are excluded.

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 a limited oral evaluation - problem focused when the services are medically necessary and reasonable. 

We looked at the file, the Plan's rules, and Medicare's rules. The record shows that the enrollee  previously received an oral exam on January 12, 2022. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation - problem focused have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided on January 31, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you think you need more therapy to get 
stronger so you can go home. The Plan denied your request. The Plan says that your request for approval of a 
continued admission in a skilled nursing facility does not meet the requirements for approval. 
 
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. The rules also say that Medicare 
health plans must make reasonable and diligent efforts to gather and forward to the Independent Review Entity 
(IRE) information regarding its decision to deny coverage or payment. 
 
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 SNF care. Our reviewer says 
that the health plans denial should be overturned. Our physician reviewer found the health plan argues that the 
enrollee has stabilized and no longer requires SNF services. The health plan cites the enrollees function at both 
the acute care hospital and the SNF, but records corresponding to these citations are not provided. Our reviewer 
also found that as such, the health plan has failed to support its argument. 
 
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 SNF care have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve 
continued skilled nursing facility (SNF) care.   
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.