Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by a tertiary care 
center. 
 
You asked the Plan to pre-approve the tertiary care services. You say that you have pancreatic cancer. The Plan 
denied your request. The Plan says there is an in-network provider that can perform the services you need. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 tertiary care services. Our physician reviewer found this diagnosis can 
be managed by an in-network provider; therefore, there is no need for a tertiary care referral. 
 
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 tertiary care services have not been met.   
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve the tertiary care services. Therefore, we decided that 
the Plan does not have to pre-approve the office services to be provided by a tertiary care center.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital services provided 
on August 20, 2021, through September 14, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Specifically, the services denied with status 
indicator G on the Plan's summary of the itemized bill are considered routine items and services. These items and services are bundled into the room and board charge and no separate payment is made. Additionally, the 
service denied with status indicator B is not supported by the documentation submitted. Therefore, we decided 
that the Plan does not have to pay an additional amount for the inpatient hospital services provided on August 
20, 2021, through September 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee has cervical dystonia and is 
requesting a referral to a non-contracted provider. The Plan denied your request. The Plan says the requested 
provider is a non-contracted provider. The Plan also says that the enrollee can be seen by Plan physical 
therapists. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment - complete (D9952) provided on 
May 24, 2022. 
 
You asked the Plan to pay for the occlusal adjustment. You say that you cannot afford the cost of this service. 
The Plan denied your request. The Plan says this service is not covered under your 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. Therefore, we decided that the Plan does not have to pay for the 
occlusal adjustment - complete (D9952) provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this power wheelchair is 
medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollees condition can be improved by a walker, cane or manual wheelchair. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental exam (D0150) provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that this procedure should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 requested item or service was exhausted on date of service February 27, 2020. 
Therefore, we decided that the Plan does not have to pay for a dental exam (D0150) provided on August 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON long-term acute care. You say that the requested location is easily 
accessible for family to monitor the care that is being received. The Plan denied your request. The Plan says 
long-term acute care is available at network facilities. 
 
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. However, the 
member has a Point of Service benefit that allows them to access out-of-network care, but at higher cost 
sharing. Inpatient services (including long-term care hospitals) may be covered out-of-network, but you will be 
responsible for 40% coinsurance for such stays. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network rate.  The member may choose to use this out-of-
network facility but will be subject to the out-of-network cost sharing. Therefore, we decided that the Plan does 
not have to pre-approve long-term acute care to be provided by an out-of-network (OON) provider.
Appeal type: Testing
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 PET scan. You say that the enrollee would benefit from this scan to evaluate 
for Alzheimer's. The Plan denied your request. The Plan says the enrollee does not meet the diagnostic criteria 
for both Alzheimer's Disease and frontotemporal dementia. 
 
The Plan follows Medicare rules. Medicare rules state that PET scan for evaluation of dementia and 
neurodegenerative diseases is only covered if certain criteria are met. 
 
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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for this PET scan. Our physician reviewer found the enrollee has a 
diagnosis of mild cognitive impairment. Neuropsychiatric testing is pending. The records do not indicate that 
the enrollee meets the diagnostic criteria for both Alzheimer's Disease and frontotemporal dementia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and the services were not referred by a network provider. The Plan also says 
that they did not approve these services in advance. 
 
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 an office visit provided on July 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease PCR (polymerase chain reaction) panel 
(87641, 87798, 88305 and 88312) provided on December 20, 2021. 
 
You asked the Plan to pay for the PCR panel. You say that this panel was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this panel was not medically necessary for 
the enrollee's condition. 
 
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 pay for the PCR panel. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that relevant literature indicates that PCR testing is not indicated as the following are 
appropriate means to verify fungal infection: direct microscopic examination with potassium hydroxide, fungal 
culture of desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. The review has 
determined that the items/services at issue in this case are not medically reasonable or 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 PCR panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the infectious disease PCR (polymerase chain reaction) panel (87641, 87798, 88305 and 88312) 
provided on December 20, 2021.
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 IRF care is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. All medically necessary care is being provided in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that there is a study for using this injection. The Plan 
denied your request. The Plan says the requested use of Opdivo is not Food & Drug Administration (FDA) 
approved or supported by Medicare for this use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
enrollee does not meet the Medicare criteria for Opdivo. Our physician reviewer found the requested use of 
Opdivo is not Food & Drug Administration (FDA) approved for the enrollee's condition and is not supported 
by the major drug compendia or by Medicare-supported medical literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Opdivo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tympanostomy and an endoscopy provided on July 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a tympanostomy and an endoscopy. You say that you are submitting 
documentation for review. The Plan denied your request. The Plan says the enrollee must receive care from a 
network 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 a tympanostomy and an endoscopy provided on 
July 19, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81455) provided on February 2, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that this testing did not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the genetic testing. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found National Comprehensive Cancer Network guidelines recommend the use of next generation sequencing 
multi-gene panels for assessing possible progression in patients with polycythemia vera. This patient has 
worsening anemia and assessment for Fibrosis or Acute Myeloid Leukemia is warranted. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for genetic testing (81455) provided on February 2, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479) provided on April 25, 2022. 
 
You asked the Plan to pre-approve the genetic testing. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 genetic testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CxBladder testing is indicated for surveillance of high-risk non-muscle invasive bladder cancer. 
This patient does not carry a diagnosis of bladder cancer and was being worked up for microscopic hematuria. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81479) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is needed by the enrollee. The Plan denied 
your request. The Plan says CardioMEMS has been determined to be of uncertain value and carries risk of 
significant complications including death and injury. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes to establish the value of CardioMEMS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on August 
02, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you are requesting 
reconsideration of the $265.00 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 $265 
copayment for ambulance services. 
 
You have been asked to pay a $265 copayment for ambulance transport. This item/service falls within the 
ambulance 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 copayment for ambulance transport 
provided on August 02, 2021.