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 regain maximum level of functioning and continue a multi-disciplinary approach to care. The 
Plan denied your request. The Plan says the enrollee is receiving the appropriate inpatient 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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac ultrasound provided on 
November 18, 2022. 
 
You asked the Plan to waive the copayment for the cardiac ultrasound. You say that you thought you were 
considered tier 1. 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 $200 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for the cardiac ultrasound. This item/service falls within the 
outpatient diagnostic tests 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 cardiac 
ultrasound provided on November 18, 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 your care. 
The Plan denied your request. The Plan says the services that you need can be provided safely in another 
setting such as at a skilled nursing facility, home with home health services, or home with outpatient services. 
 
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 clinical documentation shows that you have active medical problems. Most of 
your medical complex functional impairments have resolved. Your evaluating therapists initially recommend a 
skilled nursing facility, then additional rehab for the complexity of your documented nursing, medical and 
rehabilitation needs. Your medical needs would not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. Additionally, the documentation received does not show that 
you would tolerate and require an intensive rehabilitation regimen. IRF criteria is not 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 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 a subsequent nursing facility care visit provided on October 
31, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care 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 a subsequent nursing 
facility care visit provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953 x1), and endodontic therapy, anterior tooth (D3310 x2). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation - per site (D7953 x1), and 
endodontic therapy, anterior tooth (D3310 x2). The Plan denied your request. The Plan says the  benefit for the 
endodontic therapy, anterior tooth has already been exhausted. The Plan also says the bone replacement graft 
for ridge preservation is not covered under the enrollees 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, certain limitations apply. The record 
shows the benefit for the endodontic therapy, anterior tooth was exhausted on date of service March 23, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft for ridge 
preservation - per site (D7953 x1), and endodontic therapy, anterior tooth (D3310 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you were unable to see a network provider in 
person. The Plan denied your request. The Plan says network providers are available to render necessary care. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Breo Ellipta. 
 
You asked the Plan to pre-approve Breo Ellipta. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Breo Ellipta.  
 
Benefits for Breo Ellipta 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 12, 2022. 
 
You asked the Plan to pay for domiciliary or rest home 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 domiciliary or rest home 
visit provided on August 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation 
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested radiofrequency ablation. 
 
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 radiofrequency ablation. Our reviewer 
says that the enrollee does not meet criteria for the requested radiofrequency ablation. Our physician reviewer 
found the enrollee has chronic axial low back pain. He takes Tramadol and Tizanidine. He underwent 2 sets of 
medial branch blocks. The first set is clearly documented as having 80% pain relief. The second set degree and duration of pain relief is not documented. The lack of documentation prevents determination that the criteria of 
the LCD are met. Therefore, the request is deemed not medically reasonable and 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on 
October 05, 2022. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you thought this claim 
had been resubmitted. 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 20% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the denosumab injection. This item/service falls within the 
in-network Medicare Part B drugs 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 
the denosumab injection provided on October 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 04, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you cannot afford the 
copayment for this visit. 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 $15 
copayment for in-network urgently needed services. 
 
You have been asked to pay a $15 copayment for an urgent care visit. This item/service falls within the in-
network urgently needed 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 
an urgent care visit provided on January 04, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
2, 2022, through November 15, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary for the enrollee's 
care. The Plan denied your request. The Plan says there were no daily skilled services needed. 
 
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 pay for 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 enroll did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from November 2, 2022, through November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on 
December 13, 2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that the lab services should be 
considered preventative. 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 $450 deductible which applies to in-network outpatient diagnostic 
tests and therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $450 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the lab services were received on December 13, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for the laboratory services provided on December 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the monovisc injection provided on 
December 14, 2022. 
 
You asked the Plan to waive the coinsurance for the monovisc injection. You say that you thought this was 
fully covered in the past. 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 10% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 10% coinsurance for the monovisc injection. This item/service falls within the in-
network Medicare Part B drugs 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. The total you owe is $75.69 ($756.93 allowed amount x 10% coinsurance = 
$75.69). Therefore, we decided that the Plan does not have to waive the coinsurance for the monovisc injection 
provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one extraction, posterior-anterior or lateral skull and facial 
bone survey x-ray, cone beam CT capture and interpretation, diagnostic casts, unspecified diagnostic procedure 
and non-intravenous conscious sedation provided on October 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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. Additionally, one extraction will not be covered as it was previously 
performed on March 10, 2021. Therefore, we decided that the Plan does not have to pay for one extraction, 
posterior-anterior or lateral skull and facial bone survey x-ray, cone beam CT capture and interpretation, 
diagnostic casts, unspecified diagnostic procedure and non-intravenous conscious sedation provided on 
October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the hip replacement surgery is routine and may be performed safely with a 
48-hour observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening; prostate specific antigen (PSA) 
test (G0103) provided on December 2, 2022. 
 You asked the Plan to pay for the PSA test. You say that you had blood in your urine, but the blood had cleared 
up by the time you went in for your appointment. You also say that you did not request test, but your provider 
ordered the prostate test to be done. The Plan denied your request. The Plan says this charge exceeds the 
maximum allowable or contracted/legislated fee arrangement. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Though screening tests are not covered, prostate cancer screening tests are one of the exceptions, and limited to 
men age 50 and older, covered once every calendar year. The record shows that you received a prostate cancer 
screening; PSA test (G0103) on May 31, 2022, and your prostate cancer screening benefit had been exhausted. 
Therefore, we decided that the Plan does not have to pay for the prostate cancer screening; prostate specific 
antigen (PSA) test (G0103) provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214, 74230, and 72040 provided on 
November 17, 2022. 
 
You asked the Plan to pay for procedure codes 99214, 74230, and 72040. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit and imaging services have not been met. The documentation supports that the 
enrollee was at a skilled nursing facility on the date of service. As such, the use of the office POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for procedure codes 99214, 74230, and 
72040 provided on November 17, 2022.