Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment (D8090). 
 
You asked the Plan to pre-approve these services. You say that this is a medical necessity. The Plan denied 
your request. The Plan says that this is not a covered benefit. 
 
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 
comprehensive orthodontic treatment (D8090).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous positive airway pressure (CPAP) machine you rented on 
November 11, 2020. 
 
You asked the Plan to pay for the CPAP machine. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says that you do not meet Medicare criteria for a CPAP 
machine. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the CPAP machine by a contract provider. The file does not show that either the Plan or the 
contract equipment provider who rented this CPAP machine you to provided notice that the CPAP machine 
would not be covered. Under Medicare rules, this means the CPAP machine is considered approved by the 
Plan.  If this was not a covered item for you, or you did not meet criteria for this item, then this contract 
provider should have either not provided you with this item or disclosed to you up front that it would not be 
covered.  Neither of those things appear to have occurred here. Therefore, we decided that the Plan has to pay 
for the continuous positive airway pressure (CPAP) machine you rented on November 11, 2020.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral to an outpatient substance 
abuse program. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary in order to return to 
work and home state. The Plan denied your request. The Plan says there is no benefit for non-contracted 
providers. 
 
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 out-of-network referral to an outpatient substance abuse program.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on January 27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to you on January 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says documentation was not 
received for this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services provided to you on 
January 28, 2022. have been met. The documentation submitted does not contain medical records from the non-
contract provider. Without records, it cannot be determined the Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for the services provided to you on January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings identified with code A6530 that were 
issued on April 20, 2021. 
 
You asked the Plan to pay for compression stockings. You say that the items at issue are a medical necessity 
for you. The Plan denied your request. The Plan says rules for payment for the items at issue have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for compression stockings 
identified with code A6530 that were issued on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 4, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says excluded from 
Medicare coverage is any service other than manual manipulation of the spine for the treatment of subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance (eg, proton) imaging (MRI), pelvis; 
without contrast material(s), followed by contrast material(s) and further sequences (72197, A9585) provided 
March 6, 2020. 
 
You asked the Plan to pay for the MRI. You say that this claim should be paid. The Plan denied your request. 
The Plan says this service is not covered because prior authorization was not obtained before it was rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary. The Plan contract says that prior authorization is required for MRIs.  
 
We looked at the file and Medicare rules. In this case prior authorization was not obtained prior to the services 
being received. Based on this information, we decided that the Plans rules for coverage of the MRI have not 
been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance (eg, proton) 
imaging (MRI), pelvis; without contrast material(s), followed by contrast material(s) and further sequences 
(72197, A9585) provided March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 82542 billed for date of service April 2, 
2021. 
 
You asked the Plan to pay for procedure code 82542. You say that you have provided medical records to 
support payment of this claim. The Plan denied your request. The Plan says payment for code 82542 is bundled 
into code 40307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 82542 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 82542 billed for date of service April 2, 2021.
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 continuation of IRF care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued IRF 
care. 
 
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 
enrollee does not meet criteria for continued IRF care. Our physician reviewer found 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 was admitted for surgical repair of a femur 
fracture 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, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on January 4, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advance. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on 
January 4, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive audiometry provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for a comprehensive audiometry. The Plan denied your request. 
The Plan says the claim processed correctly. There is a $20 copay for Medicare-covered hearing exams. 
 
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 
copayment for Hearing Services.  
 
You have been asked to pay a $20 copayment for a comprehensive audiometry. The comprehensive audiometry 
falls within the Hearing 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 a 
comprehensive audiometry provided on November 2, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurology evaluation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a neurology evaluation to be provided by an OON provider. You say that 
the memory disorders clinic at the OON facility is the only available option for specialty evaluation. The Plan 
denied your request. The Plan says there are in-network specialists available to the enrollee who specialize in 
dementia and memory care. 
 
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 
a neurology evaluation to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says 
that the enrollee does not meet criteria for SNF admission. Our physician reviewer found based on the medical 
records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. Records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. Based on the medical 
records provided there is no documentation that this enrollee requires skilled therapy services; no notes from 
physical or occupational therapy have been provided. Based on the medical records provided there is no 
documentation that daily skilled services are required. Wound care is ordered every three days; no other daily 
skilled services are documented. Based on the medical records provided there is no documentation that the 
enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction procedure (92015) provided on January 17, 
2022. 
 
You asked the Plan to pay for an eye refraction. You say that the service at issue is a medical necessity for you. 
The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for an eye refraction procedure (92015) provided on January 17, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 Entyvio. Our reviewer says that the 
requirements for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial 
of Stelara and Remicade, Inflectra, or Infliximab before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
required drugs would likely be less effective or 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows it was performed in the outpatient setting. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab services (81408, 81292, 81407) provided September 
15, 2021. 
 
You asked the Plan to pre-approve the lab services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple codes were submitted for a single panel. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lab services (81408, 81292, 81407) provided September 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour blood glucose test strips. 
 
You asked the Plan to pre-approve Contour blood glucose test strips. You say that the test strips requested are 
medically necessary as the enrollee measures his blood sugar levels three times a day. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for the test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that special blood glucose monitoring systems are 
covered under Medicare if certain conditions are met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a vision 
problem/blindness that requires the use of a special glucometer/test strip, and the enrollee is not currently on an 
insulin pump or an insulin delivery device that requires a specific glucometer/test strip. Based on this 
information, we decided that Medicare rules for coverage of Contour blood glucose test strips have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Contour blood glucose test strips.