Persius/hicric huggingface dataset:
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 services are medically necessary for 
the enrollee to receive the care needed. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to a long-term 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 the documentation does not support that the enrollee has a need for complex medical 
treatment in a LTACH. The Enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate.  Denial for admission into a LTACH 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liver transplant. 
 
You asked the Plan to pre-approve a liver transplant. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 a liver transplant. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the members liver is stable on medical management. 
 
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 liver transplant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a liver transplant.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says the member does not have acute orthopedic or neurological conditions that 
require therapy at a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. SNF criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography provided on August 
31, 2022. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that there should not be a 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $170 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $170 copayment for the echocardiography. This item/service falls within the in-
network 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 the echocardiography provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on October 25, 2022. 
 
You asked the Plan to pay for injections. You say that this should be covered The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit provided on 
October 25, 2022. 
 
You asked the Plan to waive the cost share for the specialist office visit. You say that you would like the plan 
to reconsider the claim. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
 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 $800 deductible and a 10% coinsurance which applies to doctor and 
other health care provider services.  
 
You have been asked to pay $111.98 toward your deductible for the specialist office visit. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies to 
doctor and other health care provider services. This cost sharing is a contractual obligation that had not been 
met at the time the specialist office visit was received on October 25, 2022. 
 
You have also been asked to pay $12.44 coinsurance, which is 10% of the allowed amount for the specialist 
office visit. You have been asked to pay a total of $124.42 ($111.98 deductible + $12.44 coinsurance = 
$124.42). This item/service falls within the doctor and other health care provider services 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 cost share for the specialist office visit provided on October 25, 2022.
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 the services are medically necessary for the enrollee 
to receive the care needed. The Plan denied your request. The Plan says ongoing skilled care can be provided in 
an alternative 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 enrollee does not need an intensive therapy program. While the enrollee may 
benefit from physical and occupational therapy, their rehab needs can be provided in a lower intensity and 
alternate setting such a skilled nursing 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 27, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 03, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
November 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the patient is ready to be discharged home 
but needs this equipment to return home safely and prevent readmission. The Plan denied your request. The 
Plan says the patient's needs can be met with bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) mode. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has a diagnosis of 
chronic obstructive pulmonary disease (COPD) and was recently hospitalized with pneumonia. Arterial blood 
gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure. There are no pulmonary 
function tests to confirm the diagnosis of COPD and assess severity. The patient does have severe obesity and 
obstructive sleep apnea, untreated. Bilateral pleural effusions on admission suggested the possibility of heart 
failure. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. There is no 
documentation of chronic CO2 retention with an ABG done while stable. If this patient does have chronic CO2 
retention, they may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a duplex scan of extracranial arteries; complete bilateral study (93880) 
provided on November 30, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that based on a review of LCD L33627 and the corresponding LCA 
A56758, a covered diagnosis has not been billed for duplex scan of extracranial arteries (CPT 93880). The 
provider billed with a diagnosis code of Z98.890. This diagnosis code does not fall under the coding and 
billing requirements set forth in LCD L33627 and LCA A56758 as payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly.  
 
We looked at the file and Medicare rules. Specifically, the governing Local Coverage Article does not 
explicitly state that specific diagnosis codes must be billed for the service at issue. The Plan's denial has not 
been substantiated, so we must find in your favor. Based on this information, we decided that Medicare rules 
for coverage of the duplex scan have been met. Therefore, we decided that the Plan has to pay for a duplex scan 
of extracranial arteries; complete bilateral study (93880) provided on November 30, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says you 
do not have a qualifying wound for coverage of compression stockings. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, anterior (D2330) and 
resin-based composite - two surfaces, anterior (D2331) provided on November 22, 2022. 
 
You asked the Plan to pay for dental services. You say that you reviewed the enrollee's benefits online and 
confirmed that they have 100% coverage for the services received. The Plan denied your request. The Plan says 
these services are not covered under your Plan. 
 
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. Resin-based composite - one 
surface, anterior (D2330) and resin-based composite - two surfaces, anterior (D2331) are not covered under the 
Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2330 and D2331 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-
based composite - one surface, anterior (D2330) and resin-based composite - two surfaces, anterior (D2331) 
provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a comprehensive oral evaluation - new or 
established patient (D0150), panoramic radiographic image (D0330), inhalation of nitrous oxide/analgesia, 
anxiolysis (D9230), and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) 
provided on October 13, 2022, and November 22, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services represented by codes D0150, D0330, 
D9230 and D7140. You say that you were not informed about the 20% dental coinsurance for out-of-network 
providers. You also say that you could not obtain services from an in-network provider until the end of the 
year. The Plan denied your request. The Plan says this cost sharing was charged correctly.  
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 20% 
coinsurance for non-Medicare covered preventive and comprehensive dental services. 
 
You have been asked to pay a 20% coinsurance for the dental services represented by codes D0150, D0330, 
D9230 and D7140. These services fall within the dental services 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 coinsurance for a comprehensive oral evaluation - new or established patient (D0150), panoramic 
radiographic image (D0330), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), and extraction, erupted 
tooth or exposed root (elevation and/or forceps removal) (D7140) provided on October 13, 2022, and 
November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment  includes modification and 
placement (D6056), and implant supported crown - porcelain fused to high noble alloys (D6066) provided on 
January 9, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D6056 and D6066. You say that this cap 
should be covered at 50% because it's a cap like any other. You also say that the information from the Plan 
states that $3,000 for comprehensive services is covered at 50% and that's all you knew. The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
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. Therefore, we decided that the Plan does not have to pay for a 
prefabricated abutment  includes modification and placement (D6056), and implant supported crown - 
porcelain fused to high noble alloys (D6066) provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve power seat elevation feature. You say that this item is necessary. The Plan 
denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture - cast metal framework with resin 
denture bases (D5213) provided on December 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the claim because the amount 
was not explained to you before the work was done. The Plan denied your request. The Plan says your benefit 
for the maxillary partial denture $1,500 dollar limit was met. 
 
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, certain limitations apply. The record 
shows your benefit for the maxillary partial denture was exhausted on the appealed claim. Prior to the appealed 
date of service you had used $475.00 of your $1,500 dental allowance. This left $1,025.00 to be used for the 
remainder of 2022. This amount was applied to the appealed claim leaving you with a responsibility of 
$1,221.00. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture - cast metal 
framework with resin denture bases (D5213) provided on December 28, 2022.