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

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) and 2D cephalometric 
radiographic image (D0340) provided on January 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel you are not responsible for these 
charges. You say that you did not ask for noncovered services. You also say that the dentist should have 
confirmed your benefits first. The Plan denied your request. The Plan says you are covered for upper and lower 
jaw x-rays or a full series x-ray once every 36 months. The Plan says that you are not eligible to get both done 
at the same time. The Plan also says that the 2D cephalometric radiographic image is not a covered service. 
 
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 complete series x-ray is listed as 
covered, it shares a frequency limit with a panoramic x-ray and is allowed once every 36 months. The record 
shows that the Plan paid for the panoramic x-ray that you received on the date of service in this case, thus 
exhausting the benefit. Additionally, the 2D cephalometric radiographic image is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray 
(D0210) and 2D cephalometric radiographic image (D0340) provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services and office visit provided on July 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services and office visit. You say that there was a referral from the 
primary care provider and would like the procedures to be paid for. The Plan denied your request. The Plan 
says the referring and rendering providers are both out-of-network providers and there was no approved 
authorization. Also, the services rendered were not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services and office visit provided on 
July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Soliris. 
 
You asked the Plan to pre-approve Soliris. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says rules for coverage have not been met because the requested drug has 
been prescribed for an off-label and medically unsupported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Soliris. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested drug has been prescribed for a diagnosis of thrombotic microangiopathy after stem-cell 
transplant. The FDA has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Soliris.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 28, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that requests for your services accompanied by the 
actual specimen to be tests are typically sent to you directly from the treating physician. You also say that you 
have no direct patient encounter, and therefore no means of knowing if a per-authorization is required prior to 
you processing the specimen. 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 or rendered in an in-network 
facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor 
were they approved 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 laboratory services provided on November 28, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  the specialist visits provided on November 
5, 2021, November 7, 2021, and November 11, 2021. 
 
You asked the Plan to waive the copayment for the specialist visits. You say that the enrollee was admitted to 
the hospital as inpatient and that he was billed for 3 different doctors for 3 different outpatient visits and that he 
shouldn't be billed since he was admitted as inpatient. The Plan provided records showing that inpatient 
admission was denied. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment per specialist visit.  The enrollee has been asked to pay a $120 copayment for the specialist visits ($40/visit x 3 visits = $120). The 
specialist visits fall within the Physician/Practitioner services, including doctor's office visits benefit 
category. The records show the enrollee was in outpatient observation, which means separate copayments may 
apply for physician visits. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for  the specialist visits 
provided on November 5, 2021, November 7, 2021, and November 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says skilled nursing is not medically necessary as intervention of skilled trained nurse is not required. 
Additionally, there is not a requirement for medical supervision. Your needs can be safely meet at a custodial 
level of care. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/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 pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on December 26, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the DME. You say that prior authorization was obtained. The Plan denied your 
request. The Plan says the authorization was for October 1 through November 31, 2021. The December 26 date 
of service did not fall within the authorized timeframe. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the DME provided on December 26, 2021, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator 
electrode array (63650). 
 
You asked the Plan to pre-approve a percutaneous implantation of a neurostimulator. You say that the 
requested services are a medical necessity for you. The Plan denied your request. The Plan says medical 
necessity rules for the requested services have not been met. 
 
The Plan must follow Medicare rules. The rules say that the implantation of dorsal column or depth brain 
stimulators is covered when all the conditions listed in the Medicare rules section have been 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 a percutaneous implantation of a neurostimulator. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the available medical records document drug 
treatments and a home exercise program. There is no documentation of recent chiropractic, physical therapy, 
acupuncture, or other conservative modalities. There is a record of a psychological evaluation by a social 
worker; however, the requirement for psychological clearance is by a licensed psychologist or a psychiatrist. 
 
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 percutaneous implantation of a neurostimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a percutaneous implantation of a neurostimulator 
electrode array (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable foot insert (L3002). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a removable foot insert (L3002).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ataxia exome and single gene repeat expression 
analysis panel testing. 
 
You asked the Plan to pre-approve genetic panel testing. You say that these tests would be beneficial for the 
enrollee. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, 
because studies have not proven that this testing is helpful for evaluation of hereditary ataxia. 
 
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 genetic panel testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not explain how the test results will affect the enrollee's treatment 
plan. The treating neurologist notes that the mainstay treatment for ataxia is occupational, speech, and physical 
therapy which are treatments available to the enrollee already. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic panel testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Ataxia exome and single gene repeat expression analysis panel testing.
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 an inpatient rehabilitation admission is the only 
chance the enrollee may have a returning to prior level of function or higher. The Plan denied your request. The 
Plan says an IRF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says that the services at issue are not medically 
necessary. 
 
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 supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that Medicare said you needed to have 
this test done and do not know why you have to pay $104.12 out of your pocket. 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 $160 
copayment for radiological diagnostic services, including ultrasounds.  
 
The record shows this claim was approved, and you have a cost share amount. You have been asked to pay the 
allowed amount of $104.12, which is less than the $160 copayment for an ultrasound. An ultrasound 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 a retroperitoneal ultrasound provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee's pain is disabling, and 
they have failed non-operative treatment. You say that the Intracept procedure is medically necessary and the 
most effective treatment at this time. The Plan denied your request. The Plan says medical studies haven't 
proven that the service is helpful for treatment of 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 pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are multiple plausible pathologic sources of significant pain generation. 
The documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on December 21, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pay for the compression 
stockings identified with code A6530 that were issued on December 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
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 knee osteoarthritis. She 
has not tried and failed the Plan's required drugs, Supartz FX and Orthovisc. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Eurflexxa 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 Euflexxa.