Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite diabetic test strips. 
 
You asked the Plan to pre-approve the Freestyle Lite strips. You say that the enrollee requires these strips. The 
Plan denied your request. The Plan says there is no documentation supporting that only the non-preferred brand 
can meet your needs. 
 
The Plan must follow Medicare rules. The rules says that Medicare allows Plan's to establish preferred brands 
and restrict coverage to those brands as long as medically necessary non-preferred brands are covered.   
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The records submitted do not include any specific information as to 
why the non-preferred brand is medically necessary. There is no evidence that the preferred brands cannot meet 
the enrollee's needs. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Lite strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite 
diabetic test strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Botox is covered for specific indications only. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
gastroparesis. This is not a condition for which Botox is covered by the Medicare criteria. The services are 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
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. You say that the enrollee does meet LTACH 
admission criteria, and you believe that in order to sustain a safe and sustainable discharge, LTACH is the best 
option for her care. The Plan denied your request. The Plan says the criteria for admission to an LTACH have 
not been met. 
 
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 in this case the enrollee was admitted with sepsis from peripancreatic abscess and 
COVID-19 infection. The record indicates that the enrollee requires ongoing acute care services. The enrollee 
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. The elements of the coverage rules are not satisfied and 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable foot arch support orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 
removable foot arch support orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010), prefabricated abutments  includes modification and placement (D6056), and implant supported 
porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve endosteal implants, prefabricated abutments and implant supported crowns. 
You say that you have no teeth and are unable to eat. You would like to have a healthy mouth. The Plan denied 
your request. The Plan says these services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implants (D6010), prefabricated abutments  includes 
modification and placement (D6056), and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 3, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 0242U (1 Unit) remains not supported. The place of service on the CMS-1500 
form line 24B must reflect the location of the patient when the specimen was obtained.  
 The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, 
the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office 
setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 27, 2021 
and received by the lab on May 29, 2021. The submitted medical records reflect a different date of service than 
the billed date of service. Of note, the date of service is the date the specimen was collected. Therefore, the 
validity and accuracy of the claim cannot be verified. It is noted multiple attempts were made to obtain 
additional information from the provider.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate place of service code. In this case, the claim submitted does 
not reflect an accurate place of service code for the services billed. Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided 
to the enrollee on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits for ophthalmology services. 
 
You asked the Plan to waive the copayment for office visits for ophthalmology services. You say that the 
enrollee requires appointment visits (3-4 times a year at least) often coupled with specialized testing to monitor 
her condition and she is also being treated with prescription medications to prevent worsening of her condition. 
You say that if she is unable to adhere to the management plan, she risks permanent vision loss to uncontrolled 
eye disease, so any assistance in adhering to the treatment plan, whether it be financial or social services would 
help in maintaining her vision. The Plan denied your request. The Plan says coinsurance is a fixed rate that the 
member is responsible for, and it cannot be waived or reduced. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  The enrollees contract with the Plan clearly says that enrollees must pay a $45 copayment for Vision Care, 
Medicare-covered outpatient visit for and/or treat a disease or condition of the eye.  
 
The enrollee has been asked to pay a $45 copayment for office visits for ophthalmology services. The office 
visits for ophthalmology services falls within the Vision Care, Medicare-covered outpatient visit for and/or 
treat a disease or condition of the eye benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for office visits for ophthalmology services.
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 the SNF services. You say that it is not safe for you to go without this 
therapy at this time. The Plan denied your request. The Plan says the SNF services you are requesting do not 
meet the requirements for approval. 
 
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 the SNF services. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. 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. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on 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 the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an oral appliance. You say that you want to appeal the decision. The Plan 
denied your request. The Plan says this service is available within network and should not be seen by an out-of-
network provider. 
 
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 
an oral appliance to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IRF admission and services. 
 
You asked the Plan to pay for IRF care. You say that you meet the Medicare criteria for IRF and will benefit in 
ways that can't be achieved at a lower level of care. The Plan denied your request. The Plan says you do not 
meet Medicare criteria for coverage. 
 
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 pay for 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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 pay for IRF admission and services.
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 do not believe that a skilled nursing facility level 
of care will be enough for you to make a full recovery. The Plan denied your request. The Plan says you do not 
meet Medicare criteria for coverage. 
 
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 while you may benefit from physical therapy, and occupational therapy, your rehabilitation needs can be safely met in an alternate and lower intensity setting such as in an SNF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) from an out-of-
network provider. 
 
You asked the Plan to pre-approve the DME. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve durable medical 
equipment (DME) from an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 25, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services furnished after the revocation or expiration of the enrollee's hospice election until the full monthly 
capitation payments begin again. Monthly capitation payments will begin on the first day of the month after the 
beneficiary has revoked their hospice election. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 22, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility 
care provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on November 5, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that you did not know a referral was needed for 
service and you thought you were an in-network provider. The Plan denied your request. The Plan says there 
was no referral from an in-network provider for care from a non-participating provider. Services were also 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 a specialist office visit provided on November 5, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on August 25, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that it is the nursing facility's responsibility to 
obtain authorization which should cover the rendering physician's medical treatment. You say the service was 
medically necessary. 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. 
Therefore, we decided that the Plan does not have to pay for podiatry services provided on August 25, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for physician services provided on July 14, 2021, under code 99213. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists 
between codes 11042 and 99213. This PTP edit has a modifier indicator of 1, which indicates modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed.  
 
The Plan must follow Medicare rules. Medicare rules say providers must report services with the appropriate 
codes and when necessary, the appropriate modifier. In this case, this clam cannot be paid as billed due to the 
omission of the required modifier. Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee on July 14, 2021, 
under code 99213.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on November 18, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient clinic visit. You say that the visit was medically necessary for the 
enrollee to be seen and the claim should be paid. The Plan denied your request. The Plan says there was no 
referring provider, and the rendering provider is an out-of-network provider. The services were also not urgent 
or emergent, and it was not approved in advance. 
 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 an outpatient clinic visit provided on November 
18, 2021, by an out-of-network (OON) provider.