Persius/hicric huggingface dataset:
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be provided at the current facility until more 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 at this time 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Left Atrial Appendage Closure (LAAC) device. 
 
You asked the Plan to pre-approve the LAAC device. You say that the enrollee has persistent atrial fibrillation, 
putting him at risk of stroke. The Plan denied your request. The Plan says the records do not show that the 
requested procedure is medically necessary in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that an LAAC device is only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LAAC device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Left Atrial Appendage Closure (LAAC) device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility provided on May 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for admission to a skilled nursing facility. You say that the records attached support 
the services. The Plan denied your request. The Plan says the services can be obtained from an in-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 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 admission to a skilled nursing facility provided on 
May 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services and outpatient specialist 
visit on July 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient services and outpatient specialist visit. You say that 
you want to appeal the amount being charged. 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 $200 
copayment for outpatient hospital observation services. Observation services are hospital outpatient services 
given to determine if you need to be admitted as an inpatient or can be discharged. You must pay a $35 
copayment for each specialist visit, including outpatient clinic visits. Covered services include but are not 
limited to services in an emergency department or outpatient clinic, such as observation services or outpatient 
surgery. $200 + $35 = $235. Therefore, results in the total cost sharing amount of $235.  
 
You have been asked to pay a $200 copayment for outpatient services and a $35 copayment for outpatient 
specialist visit. This item/service falls within the Outpatient hospital observation and 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 outpatient services and 
outpatient specialist visit on July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
June 2, 2022, to June 24, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you want this cost sharing 
waived because it was the surgeon that caused you to be in the hospital. 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 $360 
copayment per day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay $1440 for inpatient hospital care. This amount is less than the standard cost 
sharing amount. This item/service falls within the inpatient hospital care 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 inpatient hospital care provided 
from June 2, 2022, to June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 27, 2022, billed with 
codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 27, 2022, billed with codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, and 81355.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for right leg pain after a fall. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that the enrollee 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin veneer (D2960 and D2961), a labial veneer 
(D2962), and a veneer repair (D2983). 
 
You asked the Plan to pre-approve the dental services. You say that the veneers are medically necessary. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the resin 
veneer, a labial veneer, and a veneer repair are not covered by the 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 pre-approve a 
resin veneer (D2960 and D2961), a labial veneer (D2962), and a veneer repair (D2983).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections, endoscopy, and enteroscopy provided on April 5, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for injections, endoscopy, and enteroscopy. You say that the services were medically 
necessary, and the reports attached support these services. The Plan denied your request. The Plan says there is 
no referral letter on file from an in-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 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 injections, endoscopy, and enteroscopy provided 
on April 5, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Farxiga tablet. 
 
You asked the Plan to pre-approve Farxiga. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Farxiga 
tablet.  
 Benefits for Farxiga 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammography on July 21, 2022. 
 
You asked the Plan to waive the copayment for mammography. You say that you want to appeal the amount 
being charged. 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 $35 
copayment for each basic imaging service (e.g., general x-rays or ultrasound). Covered services include, but are 
not limited to other outpatient diagnostic tests. 
 
You have been asked to pay a $35 copayment for mammography. This item/service falls within the Outpatient 
diagnostic test 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 mammography on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on August 18, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. 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 20% 
coinsurance for Medicare Part B prescription drugs. Covered drugs include drugs that usually arent self-
administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services. The provider billed in the amount of $32 and allowed amount is $5.16. 
$5.16 x 20% = $1.03. Therefore, results in the total cost sharing amount of $1.03. 
 
You have been asked to pay a 20% coinsurance for injections. 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 injections on 
August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on January 17, 2022, by an 
OON provider. 
 
You asked the Plan to pay for wound care supplies. You say that this was medically necessary. The Plan denied 
your request. The Plan says the enrollee must receive care from a 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 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 wound care supplies provided on January 17, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve the requested services. You say that it is in the enrollee's best interest to 
avoid needless radiation dosage. The Plan denied your request. The Plan says it is not the standard of care. 
 
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 while proton therapy is not an experimental therapy, any potential benefit or detriment of 
proton therapy over standard intensity modulated radiation therapy (IMRT) is an investigational question. To 
date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity 
modulated or image guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for 
prostate cancer is to only offer proton beam therapy on clinical trials, and not to routinely offer it to patients. 
The enrollee agreed to consent to a registry study.  Notably, registry studies are not clinical trials or studies, 
and have a much less rigorous development process. Therefore, the request is not medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral periapical radiographic image (D0220), 
and inhalation of nitrous oxide (D9230), and does not have to pay for endodontic therapy (D3330), local 
anesthesia (D9215), and a crown (D2740) provided from June 22, 2022, through July 6, 2022. 
 
You asked the Plan to pay more for an intraoral periapical radiographic image, and inhalation of nitrous oxide, 
and to pay for endodontic therapy, local anesthesia, and a crown. You say that the services should be covered. 
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. Endodontic therapy, local 
anesthesia, and crowns are not covered 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.  
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. 
Additionally, endodontic therapy, local anesthesia, and crowns are not covered benefits. Therefore, we decided 
that the Plan does not have to pay more for an intraoral periapical radiographic image (D0220), and inhalation 
of nitrous oxide (D9230), and does not have to pay for endodontic therapy (D3330), local anesthesia (D9215), 
and a crown (D2740) provided from June 22, 2022, through July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body (D6010) for tooth 
number 3, a second stage surgical access to an implant body (D6011) for tooth number 3, a prefabricated 
abutment (D6056) for tooth number 3 and a bone graft at time of implant placement (D6104) for tooth number 
3.  
You asked the Plan to pre-approve a surgical placement of implant body (D6010) for tooth number 3, a second 
stage surgical access to an implant body (D6011) for tooth number 3, a prefabricated abutment (D6056) for 
tooth number 3 and a bone graft at time of implant placement (D6104) for tooth number 3. You say that you 
are needing these services done in order to finish your care with the dental provider. The Plan denied your 
request. The Plan says these are not covered per the EOC. 
 
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 a 
surgical placement of implant body (D6010) for tooth number 3, a second stage surgical access to an implant 
body (D6011) for tooth number 3, a prefabricated abutment (D6056) for tooth number 3 and a bone graft at 
time of implant placement (D6104) for tooth number 3.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428-JP, A0425-
JP) provided on August 10, 2022. 
 
You asked the Plan to pay for non-emergent ambulance transportation to a physician's office. You say that 
these services were necessary and should be paid; the enrollee was transported three times on the date in 
question. The Plan denied your request. The Plan says ambulance transportation to a physician's office, clinic 
or outpatient center for a scheduled appointment is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation (A0428-
JP, A0425-JP) provided on August 10, 2022.