Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you still have a catheter. The Plan denied your 
request. The Plan says the enrollee's medical issues appear to be essentially stabilized. The Plan says that the 
enrollee no longer requires skilled services and continued 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee 
required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no 
skilled nursing needs. As of May 6, 2022, the enrollee did not require any skilled nursing or rehabilitation 
services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable 
period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living 
(ADLs.) The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As 
a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care 
as of May 6, 2022. The enrollee did not have any parental medications, complex wound care or nutrition given 
via a feeding tube. The enrollee received skilled care and improved; however, her functional improvement had 
plateaued by May 6, 2022, and she did not require any further inpatient skilled rehabilitation services. The 
enrollees function was at or near her prior level of function and she could be discharged to a lower level of 
care for further services. As of May 6, 2022, the enrollee required custodial services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), and surgical extraction (D7210) 
provided from March 8, 2021, to March 15, 2021 by the oral surgeon. 
 
You asked the Plan to pay for the dental services. You say that you had to pay out of pocket for these services. 
You say that you had to use an out of network provider due to the lack of dental providers in network in your 
area. You also say that you contacted the plan multiple times trying to find a dental provider that was in 
network. The Plan denied your request. The Plan says services must be performed by a participating general 
dentist. The Plan also says that dental services performed by an oral surgeon are not covered. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310), and surgical extraction (D7210) provided from March 8, 2021, to March 15, 2021 by the 
oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 fractions of Intensity Modulated Radiation Therapy 
(IMRT). 
 
You asked the Plan to pre-approve 20 fractions of IMRT. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 20 fractions of IMRT. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found IMRT (vs 3D) would not be in accordance with accepted standards (based on 
ASTRO model policy). The number of fractions (as 20) is justifiable, but not the need for IMRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 20 fractions of IMRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 20 fractions of Intensity Modulated Radiation Therapy (IMRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 continuation of care visits with an out of network 
(OON) neurologist. 
 
You asked the Plan to pre-approve the 9 visits with an OON neurologist. You say that the enrollee has been 
seeing the requested OON provider and has a history with him. You say that the requested provider also 
specializes in traumatic brain injuries (TBIs), which none of the network providers do. The Plan denied your 
request. The Plan says they have multiple doctors within the network who can help with the enrollee's 
condition. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 9 visits with an OON neurologist. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records 
did not indicate anything unique that would make it necessary for the enrollee to continuate care with the OON 
provider. The notes provided did not indicate any ongoing treatment with the requested provider. Rather, the 
enrollee had been referred out to skilled therapies. The Plan has identified other neurologist who are within the 
network and able to treat the enrollee and adequately address her 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 9 visits with an OON neurologist have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 continuation of care visits with an out of network (OON) 
neurologist.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for acupuncture treatment provided from May 21, 2020, through  
April 2, 2021. 
 
You asked the Plan to pay for acupuncture treatment. The Plan denied your request. The Plan says that this 
provider is not supervised by any physician, PA, or NP/CNS. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.  
 
We looked at the file and the Medicare rules. The file shows that the acupuncture treatment was provided by a 
legally qualified physician practicing within the scope of their license. Based on this information, we decided 
that Medicare rules for coverage of acupuncture treatment have been met. Therefore, we decided that the Plan 
has to pay for acupuncture treatment provided from May 21, 2020, through April 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 20, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is insufficient documentation to verify the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the chest x-ray (71045) provided on 
August 20, 2021. have been met. Specifically, the documentation submitted does not include any clinical information. We are unable to 
determine if this service was rendered or if it was medically necessary. Therefore, we decided that the Plan 
does not have to pay for the chest x-ray (71045) provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Surgical pathology services provided on December 21, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Surgical pathology services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services 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 Surgical pathology services provided on 
December 21, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there are no skilled needs identified for services. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 84153, 80061, 82306 and 
83036 provided on April 14, 2021. 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these codes have denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. In addition, medical 
documentation from the ordering provider was not provided to determine the medical necessity of the requested 
testing. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 84153, 
80061, 82306 and 83036 provided on April 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the clinical documentation provided supports the 
requested SNF care. The Plan denied your request. The Plan says the enrollee can safely receive the services 
needed in the current IRF setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
has been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF).  The enrollee has 
tolerated inpatient rehabilitation services and continues to improve with daily skilled nursing and/or skilled 
therapy services.  She could benefit from continued services at the current level of care.  The enrollee has made 
slow progress with therapy and there is no indication that transfer to a skilled nursing facility is required. She 
can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of 
care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehabilitation 
facility.  Admission to a SNF for inpatient skilled rehabilitation services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical trays (A4550) billed for date of service January 20, 2022. 
You asked the Plan to pay for surgical trays. You say that the requested items were part of an authorized 
service. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4550 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code A4550 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of surgical trays have not been met. Therefore, we decided that the Plan does not have to pay for surgical trays 
(A4550) billed for date of service January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) provided on February 8, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that this hearing aid should be covered according to 
your contract. The Plan denied your request. The Plan says hearing benefits are only provided through the 
specified hearing vendor network. The provider in this case is not part of the specified hearing vendor group. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are the specified models purchased through the Plans contracted hearing vendor.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the specified vendor network. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) provided on February 8, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and crown (D2751) provided on November 23, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
crown. You say that the crown was a result of a chip breaking off of your tooth. The Plan denied your request. 
The Plan says these services are not covered under your dental plan. The Plan also says that your 2022 dental 
coverage now extends to an allowance of up to $750 for diagnostic, preventive and restorative dental services, 
but the date of service you are appealing occurred in benefit year 2021, and your 2022 benefits cannot be used 
to cover these services. 
 
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. A problem focused limited oral evaluation (D0140) is considered to be 
a diagnostic service, and a first intraoral periapical x-ray (D0220) is only a single x-ray. Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral 
periapical x-ray (D0220), and crown (D2751) provided on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on January 19, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the enrollee did not go to the 
laboratory, so they are not using out-of-network benefits since the participating doctor sent the specimen to 
process. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for surgical pathology services provided on January 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-
rays (d0274), periapical x-rays (D0220, D0230) provided on December 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you only went to the dentist for a cleaning. You 
say that you did not want x-rays. You say that no one told you that your benefit was completely exhausted. You 
also say that you feel you should not be responsible for this bill. The Plan denied your request. The Plan says 
the annual maximum benefit of $1,500 has been exhausted. 
 
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 annual maximum benefit of $1,500 
was exhausted prior to receiving this claim. The record shows that the Plan paid $318 for services received on 
January 13, 2021, $575 for services received on March 23, 2021, and $607 for services received on May 24, 
2021. $318 + $575 + $607 = $1,500. Therefore, we decided that the Plan does not have to pay for the oral exam 
(D0120), prophylaxis (D1110), bitewing x-rays (d0274), periapical x-rays (D0220, D0230) provided on 
December 28, 2021.
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. The Plan denied your request. The Plan says the 
enrollee is currently unstable for transfer. 
 
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 in this case, the enrollee was admitted to the acute care hospital with acute infarct in the 
right lentiform nucleus, with left hemiparesis. The enrollee is slowly improving but continues to require acute 
care services. He continues to receive acute care services, and these have not been denied. The medical record 
does not indicate that the enrollee requires services that he is not currently receiving but that would be available 
at the LTACH facility. 
 
 
 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.