Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are stable and can be transferred for 
rehabilitation services. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met at an alternate level of care. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says you do not need daily skilled therapy or daily nursing care. The 
Plan says that your needs can be met with home care or in a long-term care center. 
 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 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 SNF setting. You do not meet the severity 
of illness or intensity of service criteria for an inpatient basis in a 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that the payment should not be bundled. The Plan 
denied your request. The Plan says the records do not support the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab testing services provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 3, 
2022, and ambulance services provided on June 9, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit and ambulance services. You say that 
you cannot afford to pay this. 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 $40 
copayment for in-network specialist services. Your contract with the Plan also clearly says that you must pay a 
$295 copayment for each in-network one-way trip via ground ambulance. 
 
 
 You have been asked to pay $40 copayment for a specialist office visit. You have also been asked to pay $295 
for ambulance services. The total amount you owe is $335 ($40 + $295 = $335). The specialist office visit falls 
within the specialist services benefit category. The ambulance services fall within the ambulance services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided 
on May 3, 2022, and the copayment for ambulance services provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on June 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an x-ray and an office visit provided on 
April 14, 2022. 
 
You asked the Plan to waive the copayments for an x-ray and an office visit. You say that this 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 $25 
copayment for each Medicare-covered standard x-ray service and $25 copayment for each tier 2 primary care 
visit. 
 
 You have been asked to pay a total of $50 copayment for an x-ray and an office visit. This item/service falls 
within the Medicare-covered standard x-ray service benefit category and the Physician/Practitioner Services, 
Including Doctors Office Visits 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 copayments for 
an x-ray and an office visit provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has tried and failed continuous 
positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) at home. You say that BiPAP 
only has pressure and back up rates, lacks volume, and lacks auto exhale which would cause the enrollee to 
have life threatening breath stacking. You say that not having a home ventilator will result in frequent 
hospitalization and can be detrimental to the enrollee's health by cause more health comorbidity and even 
death. The Plan denied your request. The Plan says while you have chronic obstructive pulmonary disease 
(COPD) and respiratory failure, the specific requested device will only be used in a BiPAP mode, and this can 
be achieved with a different type of device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This enrollee has chronic obstructive pulmonary disease (COPD) and was recently 
hospitalized with acute on chronic hypercarbic respiratory failure.  He improved on BiPAP.  The enrollee may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. 
There is no evidence that this has been tried and failed. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was necessary for the management of 
the enrollee's cancer. The Plan denied your request. The Plan says the claim did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (90750) and administration (90471) 
provided on May 16, 2022. 
 
You asked the Plan to pay for the immunization. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the shingles vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) and administration 
(90471) provided on May 16, 2022.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the records support this service. The Plan 
denied your request. The Plan says there is no prior authorization on file. 
 
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 August 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
March 3, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you want the Plan 
to pay for the services. The Plan denied your request. The Plan says you were not transported by ambulance to 
a medical facility, and Medicare does not cover ambulance services when transportation is not provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
provided on March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) lumbar spine 
without and with contrast. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee had injections and physical therapy prior 
to the MRI request. The Plan denied your request. The Plan says the enrollee has not completed 6 weeks of 
provider directed treatment and the treatment did not occur within the last 3 months. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found there are no records of a recent 6-week trial of 
physical therapy for back pain. More recent conservative measures are needed. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) lumbar spine without and with contrast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gym membership. 
 
You asked the Plan to pre-approve the gym membership. You say that you would like to go to a different gym 
because this gym has more benefits, such as a pool, longer hours, and closer to home. 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 covers gym benefits 
when members access to the Plan's Healthy Living Center. 
 
The Plans rules for coverage of gym benefits have not been met because the gym membership requires 
additional fees are not a part of the fitness benefit. Therefore, we decided that the Plan does not have to pre-
approve the gym membership.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total knee arthroplasty. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says physical therapy has not been tried. 
 
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 is being treated for unilateral primary osteoarthritis of the right knee. Pain has 
been present over the last 2-3 months. The right knee exam reveals full extension and 120 degrees of flexion. 
There is positive patella crepitus. However, detailed documentation is not evident regarding a trial and failure 
of recent, reasonable, comprehensive less invasive conservative care measures. There is no documentation of 
any failed physical therapy and/or physician-prescribed exercises. The results from the steroid injection 
provided on August 31, 2022, are not known. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
right total knee arthroplasty, in this case, is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a right total knee arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via Disc allograft injection services. 
 
You asked the Plan to pre-approve the Via Disc allograft injection services. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the efficacy of 
Via Disc services are still unproven and must be considered investigational. 
 
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 Via Disc allograft injection 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Via Disc procedure is experimental. More research is 
needed before coverage can be approved. 
 
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 Via Disc allograft injection services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Via Disc allograft injection services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus test (U0003) provided on November 30, 
2020. 
 
You asked the Plan to pay for the coronavirus test. You say that payment should be reconsidered based on the 
federal guidelines for COVID-19 testing and reimbursement. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 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 the coronavirus test (U0003) provided on November 30, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140), the intraoral radiographic images 
(D0220), and the bitewings (D0270) provided on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of service of April 19, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140), the intraoral 
radiographic images (D0220), and the bitewings (D0270) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for intraoral imaging (D0220), a limited oral evaluation 
(D0140), a cone beam (D0383), and retreatment of a root canal (D3348), provided by Steven Todd, D.D.S., on 
April 4, 2022, to May 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay for these 
services. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for D0220. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Your benefit limit for D0140 was previously exhausted on March 17, 2022. D0383 and D3348 are not 
covered benefits. Therefore, we decided that the Plan does not have to pay more for intraoral imaging (D0220), 
a limited oral evaluation (D0140), a cone beam (D0383), and retreatment of a root canal (D3348), provided by 
Steven Todd, D.D.S., on April 4, 2022, to May 2, 2022.