Persius/hicric huggingface dataset:
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 you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on October 3, 2022. 
 
You asked the Plan to pay for an occlusal guard. You say that you were told the guard would be covered. The 
Plan denied your request. The Plan says that an occlusal guard (D9944) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard (D9944) provided on October 3, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romosozumab-aqqg (Evenity) injections (J3111). 
 
You asked the Plan to pre-approve Evenity injections. You say that Evenity is necessary for the enrollee. The 
Plan denied your request. The Plan says based on the information provided the enrollee has not met the criteria 
for coverage. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity injections. Our reviewer says 
that the enrollee does not meet the coverage criteria for Evenity injections. Our physician reviewer found the 
Plan requires a trial of Ibandronate, Pamidronate, or Zoledronic Acid before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drugs. Our reviewer also found that there is 
no documentation provided indicating that the Plans required drugs would likely be less effective and/or likely 
have adverse effects for the 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 Evenity injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Romosozumab-aqqg (Evenity) injections (J3111).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 27, 2022. 
 
You asked the Plan to pay for an office visit. You say that this code does not require prior authorization. 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 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the claim was resubmitted as a replacement 
claim with modifier -26 added. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent urinary catheter (A4351), provided on 
August 29, 2022. 
 
You asked the Plan to pay for the intermittent urinary catheter. You say that the item should be covered. The 
Plan denied your request. The Plan says the member has exhausted to allowed amount for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that intermittent urinary catheter A4351 has an 
allowance of 200 units per month. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intermittent urinary catheter have not been met. Specifically, the documentation submitted 
indicated the member has received a total of 600 units, which is equivalent to 90-days' supply. From the first allowed unit June 12, 2022, until August 29, 2022 (denied date of service) this spans a total of 78 days. Since 
this supply is allowed 200 per month, additional units are not warranted since 600 have been paid within 78 
days. Therefore, we decided that the Plan does not have to pay for the intermittent urinary catheter (A4351), 
provided on August 29, 2022.
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 would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee is unstable 
for transfer to an LTACH. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
29, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $300 
copayment for ambulance services.  
 
You have been asked to pay a $300 copayment for ambulance services. However, you are only being asked to 
pay $250.86 which is less than the required amount. This item/service falls within the ambulance 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 ambulance services provided on 
September 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional hours of neuropsychological testing and 
psychological testing (codes 96130, 96131, 96133, 96137, 96138, and 96139). 
 
You asked the Plan to pre-approve 20 additional hours of neuropsychological testing and psychological testing. 
You say that the enrollee needs this medically necessary testing prior to surgery. The Plan denied your request. 
The Plan says the request for twenty additional hours is not substantiated in the records provided and does not 
meet medically necessary and reasonable criteria as outlined in the Local Coverage Determination (LCD) for 
Psychiatry and Psychology Services (L33632). 
 
The Plan follows Medicare rules. Medicare rules say that typically, psychological testing will require from four 
(4) to six (6) hours to perform, including administration, scoring and interpretation. Supporting documentation 
in the medical record must be present to justify greater than 8 hours per patient per evaluation. 
 
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 20 additional hours of 
neuropsychological testing and psychological testing. Our reviewer says that an additional 20 hours of 
neuropsychological testing and psychological testing is not reasonable and necessary for the enrollee. Our 
physician reviewer found a request has been made for additional hours of testing to exceed 8 hours. There was 
no clear indication in the clinical records/information provided to otherwise support the need for the extensive 
amount of coverage/testing sought in this case. Our reviewer also found that in as much, it cannot be 
independently adjudged that the request would otherwise be reasonable and necessary at this time.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 20 additional hours of neuropsychological testing and psychological testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve 20 additional hours of 
neuropsychological testing and psychological testing (codes 96130, 96131, 96133, 96137, 96138, and 96139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies. 
 
You asked the Plan to pay for incontinence supplies. You say that the items should be covered. The Plan denied 
your request. The Plan says these are not covered items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch brand diabetic test supplies. 
 
You asked the Plan to pre-approve OneTouch brand supplies. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the Plan only covers blood glucose monitors 
and test strips from Accu-Chek or Trividia brands. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may restrict coverage to certain brands of 
supplies and equipment. The Plan contract clearly says that the Plan only covers Accu-Chek or Trividia 
products. 
 
We looked at the file and Medicare rules. The requested OneTouch brand supplies are not among the Plans preferred brand of supplies. Based on this information, we decided that Medicare rules for coverage of 
OneTouch brand supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve 
OneTouch brand diabetic test supplies.
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 you cannot go home because your wife is not able to 
take care of you on her own. You say you were told you needed inpatient therapy and an intensive care team. 
The Plan denied your request. The Plan says the IRF services requested do not meet the requirements for 
approval. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services can be provided by 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 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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 home test kits provided on January 18, 2022. 
 
You asked the Plan to pay for COVID-19 home test kits. You say that you received correspondence stating that 
beginning in February of 2022, at home testing kits would no longer be reimbursable. The Plan denied your 
request. The Plan says reimbursement for home COVID-19 tests did not go into effect until February 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans may choose to cover 
at-home over-the-counter COVID-19 diagnostic tests. The Plan contract says that, effective February 1, 2022, 
members have coverage for up to eight over-the-counter at-home COVID-19 tests per member, per 30 days. 
 
 We looked at the file and Medicare rules. The records show that the test you are requesting reimbursement for 
was provided on January 18, 2022. Your Plans supplemental benefits for eight over-the-counter at-home 
COVID-19 tests was not effective until February 1, 2022. Therefore, we decided that Medicare rules for 
coverage of COVID-19 home test kits have not been met. Therefore, we decided that the Plan does not have to 
pay for COVID-19 home test kits provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on September 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service February 16, 2022. Specifically, 
the Plan contract states that a comprehensive oral exam and a panoramic radiographic image is covered once 
every three years. You previously received these services on February 16, 2022, which were paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for these services.  Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
the panoramic radiographic image (D0330) provided on September 21, 2022.
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 would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can receive the services they need in other settings. 
 
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 enrollee does not require intensive rehabilitation or frequent physician 
oversight.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595), provided on July 
8, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the items were medically 
necessary. The Plan denied your request. The Plan says a valid physician order was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. There is no date on 
the physician order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the electrical 
stimulator supplies (A4595), provided on July 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for Ondansetron 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 15, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 nursing facility care 
provided on August 15, 2022.