Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 18, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 18, 2022.
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 enrollee meets full IRF criteria. The Plan denied 
your request. The Plan says the enrollee does not meet all the required Medicare criteria for admission to an 
IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from May 14, 2021, to May 24, 
2021. 
 
You asked the Plan to pay for the evaluation and management services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the evaluation and management services was not filed until August 18, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the office visits provided from May 14, 2021, to 
May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee qualifies for the next level of 
care and is receiving Q6 antibiotics and needs extensive wound care. The Plan denied your request. The Plan 
says the request is not medically necessary, when the enrollee is ready to leave the hospital, they can safely 
receive this care in another setting, such as a Skilled Nursing Facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not indicate that the enrollee requires services that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the after-cataract laser surgery (66821) provided on July 18, 
2022. 
 
You asked the Plan to pay for the outpatient procedure. You say that you would like to appeal this denial. The 
Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
provider to inform them of the enrollee's primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the outpatient procedure until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the after-cataract laser surgery (66821) provided 
on July 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear medicine parathyroid scan (78070). 
 
You asked the Plan to pre-approve a nuclear medicine parathyroid scan. You say that the enrollee needs this 
service. The Plan denied your request. The Plan says the request does not meet the Medicare or health plan 
coverage criteria. 
 
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 a nuclear medicine parathyroid scan. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the reviewed documentation indicates that a parathyroid scan is 
medically necessary in this context when there is a parathyroid hormone level that is at least 9 times normal 
(585 pg/ml), and for localization when the surgery is being planned. In this case, the medical records do not 
show that the enrollee has a parathyroid hormone level that reaches this threshold or that localization is 
required for planned surgery. Thus, the review indicates that the items/services at issue in this case are 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 a nuclear medicine parathyroid scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a nuclear medicine parathyroid scan (78070).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment provided on October 24, 2022. 
 
You asked the Plan to pay for the medication assisted treatment. You say that the provider has been enrolled in 
the Medicare program to provide opioid treatment program (OTP) services since January 1, 2020 The Plan 
denied your request. The Plan says that payment is not allowed for this claim because it does not meet the OTP 
criteria for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says that coverage for OTP services is only available when provided by 
a facility such as a freestanding opioid treatment program facility. The claim supports that the service is being 
billed by such a freestanding OTP facility. Though a physician is noted as the rendering provider, payment is 
being made to the OTP for the services, as is required by the rules. We find that the Plan has not substantiated 
the denial of payment for these services. Therefore, we decided that the Plan has to pay for the medication 
assisted treatment provided on October 24, 2022.  
 
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: 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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 requires additional acute care that can safely be provided at the current 
facility until more stable and appropriate for transfer. The enrollee does not require services at the LTACH that 
are not already available at the current facility. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the 
literature does not support the drugs for the enrollee's circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drugs. Our physician 
reviewer found that the enrollee has a diagnosis of human epidermal growth factor receptor 2 (HER2) and 
neuroblastoma ras viral oncogene homolog (NRAS) positive metastatic colorectal cancer. The record indicates 
that the enrollee does not have RAS wild type disease. The FDA has not stated that the requested drug, 
Enhertu, is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature 
from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria for 
Enhertu are not satisfied.  Since coverage for the chemotherapeutic regimen is not available, the supportive therapy (Dexamethasone, 
Palonosetron, and Aprepitant IV) is not medically necessary. The documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
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 drugs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Enhertu.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on August 11, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you would like the store to submit the price you were 
quoted. The Plan denied your request. The Plan says the claim processed correctly. 
 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 up to a $150 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $150 towards the eyewear. The retail 
value of the eyewear was $194. ($194 - $150 = $44). The Plan applied a 20% discount. ($44 x 20% = $8.80). 
($44 -$8.80 = $35.20). Based on this information, we decided that the Plan's rules for coverage of the eyewear 
have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on 
August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on December 09, 2022. 
 
You asked the Plan to pay for an office visit (99214). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit (99214) 
provided on December 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on November 03, 2022. 
 
You asked the Plan to pay for an office visit (99214). You say that the service should be covered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit (99214) 
provided on November 03, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the foot. 
 
You asked the Plan to pre-approve an MRI of the foot. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the requested MRI is not reasonable and 
necessary. 
 
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 an MRI of the foot. Our reviewer says 
that the requested MRI of the right foot is not medically reasonable or necessary at this time.  Medical 
information enclosed for this review reveals that the patient is a type II diabetic who is being followed by their 
podiatrist for high-risk toenail care. The progress notes dated February 22, 20233 does not advise on objective 
findings concerning the enrollees right foot and ankle other than that their toenails are elongated.  
Furthermore, there is no subjective complaint on the enrollees part with regards to right foot and ankle pain.  
Medicare guidelines advise that Medicare will authorize MRIs when medically necessary and reasonable for 
the diagnosis or treatment of this specific enrollee involved.  In this case there are no subjective or objective 
findings in the progress notes that would allow for coverage of MRI of the right foot.  Therefore, the requested 
MRI of the right foot 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 an MRI of the foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an MRI of the foot.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 but is not yet stable for transfer and should only 
require additional short term acute care services that can be safely administered at the current facility until 
more stable and appropriate for 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on June 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the 
documentation did not contain medical records. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
In this case, the case file shows the appellant sent a 51-page document, but only 3 pages were included in the 
case file. The Plan did pay for some of the lab services billed, which would indicate they had documentation to 
support the paid service. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the lab services provided on June 27, 2022.  
 
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 an interim partial denture (D5820) provided on November 
21, 2022. 
 
You asked the Plan to pay for the interim partial denture (D5820). You say that you thought everything was 
planned from the very beginning. You also say that the dental office advised you the partials would be covered. 
The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 an interim 
partial denture (D5820) provided on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - one surface, posterior (D2391) 
Tooth #20, 21, and 28 provided on November 8, 2022. 
 
You asked the Plan to pay more for dental services. You say that the provider did fillings that you did not need, 
so you feel you should not have to pay for the billed services. The Plan denied your request. The Plan says the 
correct coinsurance was applied for services you received. 
 
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. This benefit includes 
restorative services - fillings white or silver  1 per tooth every 2 years. You pay 20% coinsurance for the 
following comprehensive dental services: restorative services, endodontics, periodontics, and extractions. 
 
You have been asked to pay $49.44, which is 20% of the allowed amount for resin-based composite  one 
surface, posterior (D2391). The allowed amount is $82.44 x 20% = $16.48 per tooth, $16.48 x 3 = $49.44 total. 
Therefore, we decided that the Plan does not have to pay more for resin-based composite - one surface, 
posterior (D2391) Tooth #20, 21, and 28 provided on November 8, 2022.