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

 
We decided that the Plan does not have to pre-approve implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve ILR. You say that you disagree with the Plan's denial. 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 ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of possible atrial fibrillation. While the enrollee has a history of 
possible atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, or 
any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve the requested services. You say that inappropriate treatment could cause a 
stroke. The Plan denied your request. The Plan says there is no indication how it will change the enrollee's 
medical management. 
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical indications. 
 
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 while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, or any other apparent indication for an ILR. There is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
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 an implantable loop recorder.
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 the SNF care because it will allow you to 
continue your physical therapy and occupational therapy so you can become independent. The Plan denied 
your request. The Plan says the enrollee was transferred to an inpatient rehabilitation facility where you have 
been receiving intensive rehabilitation therapies for the last 28 days. The enrollee does not need daily skilled 
services to be provided only on an inpatient basis in a SNF. The enrollee's needs may be met at a lower level of 
care. The enrollee's needs may also be met from part-time skilled services in long-term care. 
 
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 there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services daily basis. This 
enrollee does not meet 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the records do not show that the 
enrollee needs continued treatments and care that can only be given in a hospital setting. When the enrollee is 
ready to leave the hospital, they can safely receive this care in another setting like a skilled nursing facility or at 
home with home health services or outpatient setting if appropriate. 
 
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 appears to be still somewhat unstable but improving and should only 
require short-term additional acute care hospital services that can be safely administered at the current facility 
until they are more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not 
medically necessary as it would not be clinically advantageous. Completion of treatment at the current facility 
is 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urologist visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the urologist visits. You say that the services should be covered as you 
disagree with the denial and feel that the requested is the only one that can help you. The Plan denied your 
request. The Plan says the services denied correctly as they are non-emergent and can be provided in-network 
by equally as qualified providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
urologist visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on April 13, 2022. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you should not be responsible for 
this copayment. The Plan denied your request. The Plan says the copayment was applied 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 laboratory tests.  
 
You have been asked to pay a $10 copayment for laboratory services. Laboratory services 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 laboratory tests provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on April 19, 2022. 
 
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says the eye refraction 
service is not a covered benefit because it was performed with a medical diagnosis. 
 
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 eye refraction is performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that you received this eye refraction during a 
medical eye exam for age-related cataract, bilateral. The record also shows that on this date of service, you 
signed an agreement with the provider's office acknowledging that you may be responsible for a $55 charge for 
the refraction. Based on this information, we decided that the Plan's rules for coverage of the refraction have 
not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on April 19, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nuvasive allograft and bone marrow aspirate during 
approved spinal surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says medical 
studies have not proven the services are helpful. 
 
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 Nuvasive allograft and bone marrow aspirate remain experimental for use as bone graft 
material in spine surgery. More research is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Nuvasive allograft and bone marrow aspirate during approved spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to a new provider. You say that this 
should be covered because you did not have it done the year before. 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 item or service was exhausted on date of service October 1, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on April 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home healthcare services provided from September 4, 
2021, to September 16, 2021. 
 
You asked the Plan to pay for the home healthcare services. You say that you would like this claim to be 
reconsidered, because there was a lack of information provided to the servicing providers. The Plan denied 
your request. The Plan says the non-contracted provider did not submit the RAP claim for services for dates of 
service September 4, 2021, to September 16, 2021, until January 21, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home healthcare services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home healthcare services provided from September 4, 2021, to September 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on 
November 29, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. 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 testing (U0003, U0005) provided on 
November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care so you can gain mobility to help 
with your medical situation. The Plan denied your request. The Plan says the enrollee's condition requires 
management by a physician who specializes in rehabilitation. The enrollee could receive care in another 
setting. 
 
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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility.  
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that they would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee can 
receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on February 
13, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this should be covered. 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 subsequent hospital care (99232) provided on February 
13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OFEV capsules. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve OFEV capsules.  
 
Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are finding it hard to pay for this, but you 
are running the risk of losing your teeth. The Plan denied your request. The Plan says the services you received 
are not covered under your supplemental dental plan. 
 
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 pay for the 
gingival irrigation (D4921) provided on May 10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on January 3, 2022, to 
February 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 psychotherapy services provided on January 3, 
2022, to February 14, 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 diagnostic dental consultation (code D9310) you received 
on June 27, 2022. 
 
You asked the Plan to pay for the diagnostic dental consultation. You say that you were referred to this dentist 
by your regular dentist.  You said that this visit was to determine if you needed a root canal or not.  You said 
that this consultation was required, so it should be covered. The Plan denied your request. The Plan says this 
service is not covered under 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, diagnostic dental consultations are not 
among those covered under this benefit, regardless of the necessity of the service. Therefore, we decided that 
the Plan does not have to pay for the diagnostic dental consultation (code D9310) you received on June 27, 
2022.