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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on May 23, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice 
until after the transport took place. 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 ambulance service, basic life support, emergency 
transport (A0429), and ground mileage (A0425) provided on May 23, 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 you need rehab because you had surgery due to a 
hip fracture. You are trying to work with therapy assistance. Also, you have no help at home, and need two 
people to help get up and around now. You cannot go home being a fall risk. The Plan denied your request. The 
Plan says the request is not medically necessary, the services you require are being provided at your current 
facility. However, given your limited progress and therapeutic tolerance, care can safely be received at a different 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 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 skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 the enrollees physicians have agreed 
that the enrollee is stable for transfer to LTACH. In addition, they have determined that she requires close 
medical monitoring with daily physician management as well as prolonged and intensive skilled services that 
are not available at a lower level of care. The Plan denied your request. The Plan says the request is not 
medically necessary because the enrollee is receiving the care they need in the hospital where they are now and 
there is no need to transfer to the LTACH. The enrollee can stay in the hospital until they are safe for transfer 
or discharge. 
 
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 the medical records do not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules are 
not satisfied.  The requested service cannot be recommended.  
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: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not meet medical necessity criteria for admission to an IRF. 
 
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 complexity of your documented nursing, medical and rehabilitation needs would 
not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. IRF criteria are not met. 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a regadenoson injection provided on 
September 14, 2022. 
 
You asked the Plan to waive the coinsurance for a regadenoson injection. You say that you were not told you 
would be responsible for a coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a regadenoson injection. This item/service falls within the 
Medicare Part B prescription drugs 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 coinsurance for a 
regadenoson injection provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on October 17, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on October 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2022, to 
February 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. 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 looked at the file and the Medicare rules. We find that the admission date reported on the claim was not 
billed with 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 January 14, 2022, to February 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the facility fee applied to outpatient 
hospital services provided on August 9, 2022. 
 
You asked the Plan to waive the copayment for the outpatient hospital facility fee. You say that you were not 
made aware of the additional facility fee. 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 $325 
copayment for each Medicare-covered non-surgical visit in an outpatient clinic setting. 
 
 
 You have been asked to pay a $136.14 copayment for the outpatient hospital facility fee because the allowed 
amount for this service is less than $325. This item/service falls within the outpatient hospital 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 the facility fee applied to outpatient hospital 
services provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reverse the claim and not pay for an immediate lower denture 
(D5140) and an immediate upper denture (D5221) provided on August 3, 2022. 
 
You asked the Plan to reverse the claim and not pay for the dental services. You say that you would like to go 
to another dentist to get your dentures. The Plan denied your request. The Plan says your benefit for the 
requested items or services has already been exhausted. Also, the dentures were made and billed to the plan and 
paid correctly according to the plan 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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service August 3, 2022. 
Therefore, we decided that the Plan does not have to reverse the claim and not pay for an immediate lower 
denture (D5140) and an immediate upper denture (D5221) provided on August 3, 2022.  
 Your complaint about your experience with the provider is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-ray 
provided on August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan and were advised that there 
would be no charge for a second opinion. 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 date of service July 12, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic 
x-ray provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning (D1110) provided by an out-of-network 
provider on August 4, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you do not understand why the Plan is not 
covering your appointment. 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. 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 pay more for a cleaning (D1110) provided by an out-of-
network provider on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on October 3, 2022. 
 
  You asked the Plan to pay for an eye refraction (92015). You say that this provider is an approved provider for 
your medical benefit plan and the vision care plan. The Plan denied your request. The Plan says eye refractions 
are only covered by your plan if performed by a participating vision care provider and performed as a routine 
screening. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the service is performed by a Plan routine vision care provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-Medicare covered services include eye 
refractions during a routine examination when performed by a Plan routine vision care provider. The record 
shows that the provider who performed this service was not a Plan vision routine care provider. Based on this 
information, we decided that the Plan's rules for coverage of an eye refraction (92015) have not been met. 
Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on October 3, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan. 
 
You asked the Plan to pay for a positron emission tomography (PET) scan. You say that the services requested 
are medically necessary. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 pay for a positron emission tomography (PET) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found this patient 
exhibits no behavioral abnormality suggestive of Frontotemporal dementia (FTD). Absent such history the 
qualifications for a PET scan are not met. 
 
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 positron emission tomography (PET) scan have not been met. Therefore, we 
decided that the Plan does not have to pay for a positron emission tomography (PET) scan.
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 the enrollee is medically stable and ready 
to be transferred to an LTACH. You say that the enrollee is at high risk for re admission if they are transferred 
to a lower level of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can get the services they need in another 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current 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 LTACH 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 SNF care is medically necessary. 
 The Plan denied your request. The Plan says the 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628). 
 
You asked the Plan to pre-approve an intracept procedure. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is experimental. 
 
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 an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is experimental and more research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording for more than 48 
hours up to 7 days by continuous rhythm recording and storage (93243) provided on September 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was necessary 
to determine the appropriate treatment for the enrollee. The Plan denied your request. The Plan says prior 
authorization was not 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 provider in this case is not a network provider with the Plan. The ordering provider is not a network 
provider either. 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 external electrocardiographic recording for more than 48 hours up to 7 days by continuous rhythm 
recording and storage (93243) provided on September 13, 2022, by an out-of-network (OON) provider.