Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on May 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you moved to Florida in October 2020. You say 
that you went to the dentist but they did not take care of the issue. You say that you had to fly back to New 
York to have it taken care of. You say that this happened again in May 2021. You also say that you feel these 
services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is 
covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan 
also says that the frequency limits have been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
the frequency limits of once every 3 plan years have been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation and complete series x-ray that you received on November 11, 2020. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
and shoulder for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is lack of clinical information to support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found physical therapy as well 
as a home exercise program have been prescribed, but not yet started. There are no red flags to mandate 
immediate imaging of either the lumbar spine or shoulder without a trial of the already prescribed physical 
therapy. 
 
 
 
 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine and shoulder for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 5, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that services were provided to the enrollee so the 
claim should be paid. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers and there was no approved authorization. Also, services provided was not urgent 
or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 5, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is requested versus a lower level 
of care as he will require another 4-6 weeks of transitioning from this acute illness. You say that recovery can 
be met faster in an LTACH setting so the transition is very benefit. The Plan denied your request. The Plan 
says admission to an LTACH should not take the place of completion of treatment in an acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record does not indicate that the enrollee requires services that he is 
not currently receiving that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied, and the requested service cannot be recommended. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on August 27, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were told that the copayment 
would only be $60. The Plan denied your request. The Plan says the claims were processed correctly and the 
enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for CT scans. 
 
 
 
 
 
 
  
 
The enrollee has been asked to pay the allowed amount of $113.88, which is less than the $200 copayment for 
a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on August 
27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the enrollee has failed treatment with Avastin, so Eylea 
should be used to continue treatment. The Plan denied your request. The Plan says the denial of authorization 
for this drug is correct, because the Plan requires a trial of Lucentis before it will approve Eylea. 
 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 Eylea. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Eylea. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drug of Lucentis. The record does not show that 
this drug will be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Eylea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on October 6, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you went to the provider specified by the Plan, but 
they never told you that the hearing aids you chose were not covered by your benefit. The Plan denied your 
request. The Plan says the hearing aids purchased in this case are not on the Plan's formulary and are not among 
those covered under this benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays only 
for the hearing aids provided by the Plans specified vendor and listed in the Plans contract. 
 
We looked at the file and the Plan's rules. While the Plan offers a supplemental benefit in excess of Medicare 
coverage and the provider in this case is the Plans specified routine vendor, the hearing aid model purchased 
are not among those covered by this benefit. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids purchased on October 6, 2021.  
 
Your complaint about potential missing information from a Plan provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx panel (0239U) provided on 
August 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx. You say that you would like reconsideration 
because this test is covered by Medicare and the laboratory is not responsible for obtaining authorization. The 
Plan denied your request. The Plan says prior authorization was not obtained for this testing. 
 
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 the FoundationOne Liquid CDx panel (0239U) 
provided on August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a PT evaluation provided on February 4, 
2021. 
 
You asked the Plan to waive the deductible for a PT evaluation. You say that you met the deductible and 
should not be responsible for the charges. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient rehabilitation services.  
 
You received a PT evaluation on February 4, 2021. The record shows that you had only paid $330.03 toward 
the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of 
$87.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time a PT evaluation was received on February 4, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for a PT evaluation provided on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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 present setting 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. 
 
   
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on March 11, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the referring provider is a non-participating provider, and the Plan did not 
authorize any services for this 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 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 (G0482) provided on March 11, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient's needs cannot be 
accomplished at a lower level of care, and they are ready for the LTACH admission. You say that the patient's 
health and recovery will be adversely affected if admission is further delayed. The Plan denied your request. 
The Plan says the member is receiving the necessary care at the current hospital and there is no need to transfer 
to the LTACH at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the medical record does not indicate that the enrollee requires services that he is 
not currently receiving that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied, and the requested service cannot be recommended 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee presented to the 
hospital on February 28, 2022 with a ground level fall and right femur fracture. As of March 8, 2022 she is 
reported to be medically stable for discharge. The complexity of her nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Her 
medical conditions are stable on outpatient medications with no issues that require a physicians evaluation 
three or more times per week. She requires physical and occupational therapy but does not require an intensive 
therapy program in an IRF. It does not appear that she requires the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with a femur fracture and underwent surgical repair. The therapy notes dated March 10, 2022 show he 
is not yet taking significant steps.  The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. He does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. There is not a reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) 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 has been no documented trial of conservative therapy demonstrating failed 
response to treatment. 
 
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 record indicates that the enrollee has edema due to cirrhosis and venous insufficiency. The record 
provided does not document that the enrollee has edema that extend to the trunk and that a four week trial of a 
basic pump has failed. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules,  of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 a pneumatic compression device (E0652, E0667) for the enrollee.