Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the head or brain for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the information provided in the medical records does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee's history of 
COVID-19 infection in the past makes her a candidate for Long Hauler syndrome. Furthermore, the noticeable 
mental status change is a valid indication for CT of the brain and the exam should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the head or brain for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on November 3, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on November 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 
23, 2021, to May 1, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be 
covered as it is the providers fault that you received the services in the first place. The Plan denied your 
request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 per day for days 1-6 of Inpatient hospital care.  
 
 
 You have been asked to pay a $1,200 copayment for six days of inpatient hospital care ($200 x 6 = $1,200). 
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 April 23, 2021, to May 
1, 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 had open heart surgery twice and were on a 
ventilator for an extended period of time. 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 your rehabilitation needs can be met safely at a lower intensity and alternate setting 
such as in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
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 you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
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 record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the breast with computer-
aided detection (CAD) for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there must be results from a recent mammogram, breast ultrasound, or biopsy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found screening mammogram 
followed by left diagnostic mammogram were done which revealed a nodular density in the left 
breast. Ultrasound was then done revealing a heterogeneous corresponding nodule for which MRI was 
recommended by the radiologist. MRI is the procedure of choice to determine if biopsy is warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the breast with computer-aided detection (CAD) for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on November 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that 
periapical x-ray is not listed as a covered service either. 
 
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 limited oral evaluation and 
periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical 
x-ray (D0220) provided on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no red flags for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found detailed documentation 
is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative 
care measures since the increase of the low back pain. Additionally, detailed evidence of severe and/or 
progressive neurological abnormalities has not been documented. Previous exams were not provided to 
demonstrate any significant worsening of neurological abnormalities. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the request for magnetic resonance imaging (MRI) of the lumbar spine is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator with settings that could be delivered 
by bilateral positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) for this 
enrollee with bronchiectasis is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the Life2000 
system is not medically necessary. This device is not a ventilator because it is not capable of providing full 
ventilatory support. It has not been shown to be beneficial in the treatment of lung disease in controlled clinical trials. You have severe chronic obstructive pulmonary disease (COPD) and pulmonary hypertension, related to 
primary ciliary dyskinesia. A venous blood gas (VBG) study suggests CO2 retention, although this has not 
been confirmed with an arterial blood gas (ABG) study, done as an outpatient while stable. You may benefit 
from ventilatory support during sleep (bilateral positive airway pressure - BiPAP). But Medicare does not 
cover a home ventilator when used as BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on August 24, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. 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 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 the office visit (99213) provided on August 24, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the electrocardiograms (ECGs) and 
specialist office visits provided by network providers from April 14, 2021, to August 18, 2021. 
 
You asked the Plan to waive the copayments for the ECGs and specialist office visits. You say that these 
claims were processed incorrectly. The Plan denied your request. The Plan says you have been asked to pay the 
correct cost-sharing amount. 
 
 
 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 other in-network outpatient diagnostic tests and a $40 copayment for in-network specialty care 
physician.  
 
You have been asked to pay a $10 copayment for the ECGs on April 14, 2021, and August 18, 2021. You have 
been asked to pay a $40 copayment for the specialist office visits on August 3, 2021, and August 18, 2021. The 
ECGs fall within the Outpatient diagnostic and therapeutic services and supplies benefit category. The 
specialist office visits fall within the Physician/Practitioner services, including doctors office visits benefit 
category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the electrocardiograms (ECGs) and specialist office visits 
provided by network providers from April 14, 2021, to August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system and power seat elevation 
system with connections.  
 
You asked the Plan to pre-approve a power wheelchair and several accessories for the enrollee. The Plan says 
while the power wheelchair and Medicare approved accessories were approved, an expandable control system 
and power seat elevation system with connections is not covered.   
 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare specifically states the E2300 power seat elevations system and related 
connections 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 expandable control system. Our 
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found based on the medical 
records there is no documentation that supports that the requested controller, harness, and connection meet 
Medicare criteria for medical necessity for the enrollee's use. Although the provided records document that the 
enrollee has severe lower extremity weakness, the records do not document deficits in upper extremity strength 
or range of motion such that he is unable to operate the available power options with their own switches. 
Medicare coverage 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 expandable control system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve expandable control system necessary for the enrollee's wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close physician monitoring, 
twenty-four (24) hour nursing, and continued care by their consulting physicians to monitor and manage their 
medical status. The Plan states inpatient rehabilitation will decrease the risk of a repeat hospitalization with 
emphasis on improving the enrollee's overall functional status with a goal of returning home with their spouse. 
You state that you believe the enrollee's medical management and rehabilitation needs require an inpatient 
rehabilitation admission. The Plan denied your request. The Plan says the stay is not medically necessary based 
on IRF criteria. The Plan states the enrollee can safely receive the services they need in other settings, for 
example: a skilled nursing facility. 
 
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 review indicates that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute 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, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this 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 IRF admission and services.
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 improving and requires only short-term additional acute 
care services that can safely be administered 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 a lower level of 
care may be considered when treatment is completed. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the crown (D2740) and core 
build up (D2950) provided from September 22, 2021, to October 13, 2021. 
 
You asked the Plan to reimburse an additional amount for the dental services. You say that you were misled by 
the representative. You say that your insurance only paid for a quarter of the bill. You say that they were 
supposed to pay for half. You also say that you want to be reimbursed an additional amount. The Plan denied 
your request. The Plan says that dental services are covered at 50% of the cost. 
 
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 and the services are listed as covered, 
there is a 50% coinsurance that applies to the cost, or allowed amount, of the services.  The record shows that the Plan paid 50% of the allowed amount for the services. Therefore, we decided that the 
Plan does not have to reimburse an additional amount for the crown (D2740) and core build up (D2950) 
provided from September 22, 2021, to October 13, 2021.