Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a PT service provided on May 2, 2022, with 
an out-of-network provider. 
 
You asked the Plan to waive the deductible for a PT service. You say that you and your primary care provider 
checked that the PT provider was in-network, and the Plan should be covering this service as they have done 
previously. 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 $750 deductible which applies to outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient rehabilitation 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time physical therapy service was received on May 2, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for a PT service provided on May 2, 2022, with 
an out-of-network provider.
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 you are not well enough to go home, and 
the skilled nursing and rehab facilities cannot handle your needs. The Plan denied your request. The Plan says 
based on Medicare guidelines, the LTACH services requested do not meet the requirements for approval. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. The Plan has approved ongoing care 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided September 14, 2022, to 
September 16, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient stay was medically 
necessary. The Plan denied your request. The Plan says that observation level of care was more appropriate. 
 
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 supports that the criteria for inpatient payment 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 patient's necessary hospital care (including earlier ED 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 pay for the acute inpatient hospital care provided September 14, 2022, to September 16, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization with angioplasty and stent placements. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
requested services are not medically necessary. 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 requested services. Our physician 
reviewer found that the enrollee has electromyography (EMG) evidence of severe peripheral neuropathy. The 
description of the enrollees leg symptoms is inadequate. The documentation does not support that the 
enrollees leg symptoms are due to arterial occlusive disease and does not document that the symptoms are 
lifestyle limiting. There is no evidence of limb threat. No lower extremity pulse examination was provided. No 
noninvasive vascular study of the lower extremities was provided. The documentation does not support the 
medical necessity of the procedure and does not provide a satisfactory indication. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revascularization with angioplasty and stent placements.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 5, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee started hospice the same day but 
did not start until after the patient was transported and dropped off at their destination. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable cardioverter defibrillator (ICD). 
 
You asked the Plan to pre-approve ICD. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that an ICD may be covered only 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 ICD. Our reviewer says that the 
enrollee does not meet the criteria for an ICD. Our physician reviewer found the enrollee has a documented 
ejection fraction of 38%, which is above the threshold for prophylactic ICD implant. Thus, this would not be 
considered 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 ICD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable cardioverter defibrillator (ICD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a crown 
(D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64490 and 64491 billed for date of service 
April 28, 2022. 
 You asked the Plan to pay for procedure codes 64490 and 64491. You say that you performed services as per 
the needs of the enrollee. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
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 64490 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Additionally, code 64491 is an add-on code reported in addition to the primary 
procedure code. Since the primary procedure code 64490 has been denied, the add-on code 64491 is not 
payable at this time. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 64490 and 64491 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 64490 and 64491 billed for date of service April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a denture relining 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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 pre-approve a 
denture relining
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 18, 2022, 
to March 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 18, 2022, to 
March 9, 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 enrollee's needs cannot be safely met by skilled 
nursing or home health at this time and requires management by direct physician supervision. The Plan denied 
your request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have not 
been met. 
 
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 enrollee does not require treatment by multiple therapies or an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 
 
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 waive the copayment for lab services provided on September 26, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you think this service should be 
covered. 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 $10 
copayment for other Medicare-covered laboratory tests, besides a fecal immunochemical test (FIT). 
 
You have been asked to pay a $10 copayment for lab services. This item/service falls within the other 
Medicare-covered laboratory tests, besides a fecal immunochemical test (FIT) 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 lab services provided on September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide visits. 
 
You asked the Plan to pre-approve the additional home health aide visits. You say that a home health aide is 
needed to manage the enrollee's home care needs. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional home health aide visits. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
the enrollee does not have documented skilled needs. The services of home health aides are not shown to be 
medically necessary to assist in the treatment of an acute illness or injury. The requested services are not 
medically necessary, reasonable or coverable.  
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 additional home health aide visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional home health aide visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek brand diabetic testing supplies. 
 
You asked the Plan to pre-approve Accu-Chek brand supplies. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the Plan only covers OneTouch brand diabetic testing supply products. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may restrict coverage to certain brands, 
items, and supplies. The enrollees contract with the Plan clearly says that OneTouch products are the Plans 
preferred brand of diabetic test supplies.  
 
We looked at the file and Medicare rules. The requested Accu-Chek brand supplies are not the Plans preferred 
brand. The Plan has not approved authorization to use a non-preferred brand. Based on this information, we 
decided that Medicare rules for coverage of Accu-Chek brand supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Accu-Chek brand diabetic testing supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) and 
computed tomography (CT) scan provided on July 14, 2022, and September 14, 2022. 
 
You asked the Plan to waive the copayment for MRI and CT scan. You say that you should not have to pay the 
copayment for these appointments because you were not told ahead of time there was a charge. 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 $325 
copayment per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. 
  You have been asked to pay $605.42 for the MRI and CT scan .You were billed $280.42 for the MRI, which is 
less than the standard $350 copayment. You were billed $350 for the CT scan, which is the correct copayment 
amount. This MRI and CT scan fall within the Outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for magnetic resonance imaging 
(MRI) and computed tomography (CT) scan provided on July 14, 2022, and September 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs. 
The enrollee's care needs, custodial and intermittent, can be provided at a lower level of care. 
 
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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy provided on October 13, 2022. 
 
You asked the Plan to pay for biopsy. You say that you are appealing the claim payment denial. 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 biopsy provided on 
October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the food purchased from Jenny Craig provided on January 1, 
2022. 
 
You asked the Plan to pay for the food purchased from Jenny Craig. You say that you want to be reimbursed 
the weight management allowance. You say it was not explained to you that food was not included in the 
benefit. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan only covers program 
fees for weight loss programs. 
 
The Plans rules for coverage of gym benefits have not been met because the Plan does not cover costs for pre-
packaged meals or food. Therefore, we decided that the Plan does not have to pay for the food purchased from 
Jenny Craig provided on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty (D7310). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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 pre-approve an 
alveoloplasty (D7310).