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

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and panoramic x-ray 
(D0330) provided on December 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had an infected tooth. You say that the 
dentist came into the office on his day off. You say that they suggested going to an oral surgeon. You also say 
that you were surprised and disappointed to get this denial. The Plan denied your request. The Plan says 
coverage for a limited oral evaluation is limited to once per plan year. The Plan says that coverage for a 
panoramic x-ray is limited to once 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 have been exceeded. The record shows that the Plan paid for a limited oral evaluation and 
panoramic x-ray that you received on November 16, 2021. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested bed. You say that the enrollee's previous bed is broken. The 
Plan denied your request. The Plan says the height adjustment is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stairway elevator. 
 
You asked the Plan to pre-approve the elevator. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stairway elevator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on December 4, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed once by the emergency 
department and the other was billed by a critical care provider after the enrollee was admitted to the intensive 
care unit. The Plan denied your request. The Plan says this service was billed twice on the date in question but 
is only allowed to be billed once per Medicare guidelines. The first instance of this service was already 
processed and paid. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of critical 
care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour 
(99291) provided on December 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-laboratory Polysomnography. 
 
You asked the Plan to pre-approve an in-laboratory Polysomnography. The Plan denied your request. The Plan 
says a home sleep study would be appropriate, however there is no documentation provided that supports the 
medical necessity of an in-lab study. 
 
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 an in-laboratory Polysomnography. Our 
reviewer says that the requested in-laboratory Polysomnography is not considered medically reasonable and 
necessary in this case. Our physician reviewer found an at home polysomnography test would be sufficient 
based on the provided documentation as there was no contraindication to such or special circumstances that 
would warrant in-laboratory testing. You do not have severe lung disease, heart failure, morbid obesity, or a 
neurodegenerative disorder. You tolerated the first in-home polysomnography test already without issues. 
Therefore, the in-laboratory polysomnography will be considered not medically necessary based on the 
documentation provided.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an in-laboratory Polysomnography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an in-laboratory Polysomnography.
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 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 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with a recurrent urinary tract infection. The record indicates that she suffered a hip 
fracture while hospitalized that was treated non-operatively. She requires ongoing acute care services that have 
not been denied. She continues to receive acute care services at the current facility. She does not require any 
services that she is not currently receiving that would be available at the LTACH. The LTACH services are not 
reasonable or 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-emergency transport (A0100). 
 
You asked the Plan to pre-approve the non-emergency transport. You say that the service is medically 
necessary. The Plan denied your request. The Plan says you have exhausted the Plan benefits for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve the non-emergency transport (A0100).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis (74176) provided on December 14, 2021. 
 You asked the Plan to pay for a CT scan of the abdomen and pelvis. You say that you have provided medical 
records to support the level of service. The Plan denied your request. The Plan says rules for payment have not 
been met because the CPT code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74176 
is a column II code to column I code 74175. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and pelvis 
(74176) provided on December 14, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve two additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found you have a history of a right rotator cuff 
repair and have been undergoing physical therapy. Per the clinical documentation, the continued skills of a 
professional therapist are required. The physical therapist clearly states short- and long-term goals that are 
reasonable and not yet met. The continued services are 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve two additional physical therapy (PT) visits.  
 
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 the expandable controller upgrade (E2377), harness 
(E2313), power seat elevation system (E2300), electronic connection (E2311), power seat (E1012), power seat 
tilt and recline (E1007), power tech vent (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories.. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the accessories do not serve primarily a medical purpose and/or 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  Medicare rules also 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 wheelchair accessories. Our reviewer says that these 
items are not medically necessary. Our physician reviewer found the enrollee is not high risk for skin 
breakdown, does not utilize a catheter for bladder management and does not have documented increased tone 
or spasticity to qualify for the power tilt/recline. The power seat elevation feature is statutorily non-covered as 
it serves no primary medical purpose. Records do not document a cast or condition preventing 90 degree 
flexion at the knee or significant lower extremity edema to qualify for the power leg elevation feature. As the 
power tilt/recline and elevating leg rests cannot be covered, the electronic connection, harness and expander 
cannot be covered. The power tech vent does not meet criteria for reasonable and necessary based on available 
records. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the expandable controller upgrade (E2377), harness (E2313), power seat 
elevation system (E2300), electronic connection (E2311), power seat (E1012), power seat tilt and recline 
(E1007), power tech vent (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (Q0138) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the provided records do 
not indicate that the enrollee has tried and failed the plan's preferred step one alternative - Venofer or Infed. 
The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from 
the plan's preferred step one alternative. 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme (Q0138) for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inflectra. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis. 
She has not tried and failed the Plan's required drugs, Enbrel, Humira, Rinvoq, Xeljanz, or Xeljanz XR. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Inflectra is 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Inflectra.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole 4MG capsule. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Omeprazole is a self-administered drug and does not fall under Part B 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 Omeprazole 4MG capsule.  
 Benefits for the medication 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 9, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 office visit provided on December 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the 
pelvis provided on November 17, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you reached your MOOP in August and 
have had no copayments. You also say you do not understand why you must pay the $40 copayment. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $40 
copayment for diagnostic radiology services. The Plan contract also says that enrollees must pay a $7,550 
maximum out-of-pocket (MOOP) per calendar year. 
 
The record shows a previously submitted claim was adjusted, which caused you to fall below your MOOP. 
Therefore, you are responsible for the cost sharing amount. You have been asked to pay a $40 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 magnetic resonance imaging (MRI) of the pelvis provided on November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beyond May 12, 
2022. 
 
You asked the Plan to pre-approve these services. 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 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on May 4, 2022 with major neurocognitive disorder with behavioral disturbance, most likely due to 
Alzheimer's disease. Based on the records, it is not expected that she will improve in a reasonable period of 
time, as she does not have suicidal or homicidal ideation and does not have auditory or visual hallucinations. 
She is complaint with treatment and is not showing any acute threats to safety. It does not appear that active 
treatment is taking place beyond the dates in question. The services are not reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis beyond the date in question. The continued services are not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services beyond May 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient rehabilitation services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the service is 
available by a provider in the enrollees network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient rehabilitation services to be provided by an out-of-network (OON) provider.