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

 
We decided that the Plan does not have to pre-approve a panoramic x-ray (D0330). 
 
You asked the Plan to pre-approve the dental service. You say that this service should be covered. The Plan 
denied your request. The Plan says panoramic x-ray 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, the requested panoramic x-ray is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
panoramic x-ray (D0330).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on 
December 2, 2021. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that this is your regular 
neurologist and insurance should cover the charges. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
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 $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the specialist office visit was received on 
December 2, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a specialist 
office visit provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
enrollee does not meet the Medicare criteria for a therapeutic CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 therapeutic CGM. Our reviewer says 
that the enrollee does not meet the Medicare criteria for a therapeutic CGM. Our physician reviewer found the record indicates that the enrollee has diabetes and uses insulin twice daily. 
The records do not indicate that the enrollee adjusts the insulin dosage frequently based upon measured glucose 
values. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the scrotum and contents (76870) provided 
on October 5, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that this claim was denied in error and this service is 
supported in the medical record. The Plan denied your request. The Plan says two of this service was billed on 
this date. This service may only be billed once per enrollee per day. 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 76870 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 the 
ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound of 
the scrotum and contents (76870) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on October 16, 
2021, by an OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the provider depends on the 
facility to obtain proper authorization. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not 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 the domiciliary or rest home visit provided on 
October 16, 2021, by an OON provider.
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 enrollee can get better care at the 
LTACH. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current 
acute setting. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with progressive shortness of breath. 
She is ventilator dependent. She had a feeding tube placed. She is receiving appropriate care at the present 
acute care hospital. There are no services available at the LTACH that she requires that are not available at the 
health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthotic device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is an experimental device. 
 
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 MyoPro orthotic device. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current clinical guidelines designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment and there are no records from the enrollees actual treating provider clarify why the requested 
device is the most appropriate treatment for the enrollees condition. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro orthotic device (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 28, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on November 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is needed because you need 
more assistance and cannot care for yourself at home. The Plan denied your request. The Plan says SNF 
admission is not medically necessary. 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you have no identifiable skilled nursing 
needs.  While you do have skilled therapy needs, you do not need this therapy on a daily basis in an inpatient 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient psychiatric care. 
 
You asked the Plan to pre-approve the inpatient psychiatric care. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. 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 the inpatient psychiatric care.  Our reviewer says that the service is not medically necessary. Our physician reviewer found it is not expected 
this enrollee would improve in a reasonable period of time for the dates in question as she does not have 
suicidal or homicidal ideation, auditory or visual hallucinations and is compliant with treatment while not 
showing any acute threats to safety. 
 
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 inpatient psychiatric care have not been met. Specifically, medically 
necessary services can be obtained in a lower level of care. This means continues inpatient psychiatric care is 
not reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve the inpatient 
psychiatric care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lab services provided on November 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a drug test. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the care was not approved in compliance with the health plan's 
authorization procedures. 
 
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 Lab services provided on November 29, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that please review the attached documentation 
for reconsideration authorization. The Plan denied your request. The Plan says the records do not support that 
the enrollee meets the medical necessity criteria. 
 
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.  
 
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 power scooter. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does indicate that the enrollee has a mobility deficit but the 
documentation does not reveal that this deficit significantly impairs MRADLs in the home and this mobility 
limitation is not ameliorated by a manual wheelchair. A 10/12/21 PA office note states the enrollee is able to 
use the bathroom, stand, cook dinner, dress, feed, bathe without difficulty with the use of an assistive device 
such as a cane or walker. While the enrollee may have the cognition to safely operate the requested K0800 
device the documentation does not reveal that the K0800 will  significantly improve the enrollees ability to 
participate in MRADLs and the enrollee will use it in the home. The documentation does not reveal  that the 
requested power operated vehicle is medically necessary per Local Coverage Determination (LCD):(L33789). 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the power operated vehicle, group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo 
this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient 
Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation 
provided to support the expectation the enrollee will require a greater than two midnight 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. Specifically, services can be 
obtained in a lower level of care. Therefore, we decided that the Plan does not have to pay for the acute 
inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services (V5010, V5160, V5261, V5265) 
provided on August 12, 2021. 
 
You asked the Plan to pay for the hearing aid services. You say that this claim should be paid. The Plan denied 
your request. The Plan says another insurance provider is the enrollee's primary insurer. Payment or denial 
information from the primary plan is necessary to proceed with this claim. 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, 
as the provider, to send this claim to the primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the hearing aid services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the hearing aid services (V5010, V5160, V5261, 
V5265) provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from November 
11, 2021, to November 16, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are appealing the 
cost sharing. The Plan denied your request. The Plan says the copayment applied is 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). Your contract with the Plan clearly says that you must pay a $295 
copay per day, for the first five days, for Medicare-covered hospital care.  
 
 
 You have been asked to pay a $1,475 ($295x5) for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient Hospital Care 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 inpatient hospital stay from November 11, 2021, to November 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any 
documented skilled nursing or skilled therapy needs. 
 
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 SNF care have not been met. Specifically, medically necessary services can 
be obtained in a lower level of care. This means SNF care is not medically necessary. Therefore, we decided 
that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the patient would not be safe at home alone and he 
needs a higher level of help than his family can provide. The Plan denied your request. The Plan says SNF care 
is not medically necessary. 
 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 from a nursing perspective, the patient 
received oral medications and has stable vital signs.  He underwent right colectomy for a cecal mass and has 
been treated for pain. Regarding rehabilitation services, the patient has received physical and occupational 
therapy.  The patient was at a contact guard assist for functional mobility including gait to 65 feet and required 
varying assist with activities of daily living. The patient currently has no skilled nursing needs, but does not 
skilled therapy needs.  However, the patient does not require therapy on a daily basis in an inpatient 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) care.