Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing services. 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 genetic testing services. You say that this genetic 
testing is medically necessary based on your family history. The Plan denied your request. The Plan says the 
criteria for coverage for the requested genetic testing have not been satisfied. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing is considered 
medically necessary for a beneficiary with a current diagnosis, or a personal history of a cancer associated with 
the BRCA mutation. 
 
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 BRCA1 and BRCA2 genetic testing 
services. Our reviewer says that the requested BRCA1 and BRCA2 genetic testing is not medically reasonable 
and necessary. Our physician reviewer found you have no personal history of breast cancer, but 2 first degree 
cousins have been diagnosed with breast cancer. In this case, since you have no personal history of breast 
cancer BRCA1 and BRCA2 testing is not indicated for coverage 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 BRCA1 and BRCA2 genetic testing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service with no transportation provided on 
November 20, 2021. 
 
You asked the Plan to pay for ambulance service. You say that it was the right decision to not transport the 
enrollee to the hospital. The Plan denied your request. The Plan says ambulance service with no transportation 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 20, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance service with no transportation provided 
on November 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided from January 22, 2022, 
to January 24, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the medically necessary services were rendered to 
the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care provided from January 22, 2022, to January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye test on December 27, 2021. 
 
You asked the Plan to waive the copayment for an eye test. You say that you should not have a $30 copayment 
for this visit, as this provider did not do anything differently than your previous providers, who you did not 
have copayments for. The Plan denied your request. The Plan says you must pay a $30 copayment for 
Outpatient Diagnostic Tests and Therapeutic Services. 
 
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 $30 
copayment for Outpatient Diagnostic Tests and Therapeutic Services. The other code the provider used, was for 
this. 
 
You have been asked to pay $30 copayment for an eye test. An eye test falls within the Outpatient Diagnostic 
Tests and Therapeutic 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 
an eye test on December 27, 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 IRF admission is necessary because a Skilled 
Nursing Facility (SNF) would not meet your needs. An IRF has the necessary tools to treat your conditions 
while also supporting your mental health, unlike a SNF. The Plan denied your request. The Plan says the rules 
for IRF admission have not been met. The Plan says your skilled therapy and nursing needs can be safely 
provided at a lower level of care. A SNF, long-term care, or home health setting would be appropriate to meet 
your medical needs. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not necessitate 
admission to an IRF. You were admitted to an inpatient hospital for weakness, shortness of breath, and chronic 
diarrhea. These medical problems are now stable; you have no complex nursing or rehabilitation needs. Our 
reviewer also found that the medical record supports a need for physical and/or occupational therapy, but the 
documentation does not support a need for intensive rehabilitation services. Furthermore, our reviewer says 
there is no reasonable expectation that you will be able to fully participate in and benefit from the type of 
intensive rehabilitation therapy program provided in an IRF 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 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 the hearing aid (V5298) provided on November 15, 2021 by 
a non-participating provider. 
 
You asked the Plan to pay for the hearing aid. You say that you preferred to get the same hearing aids you had 
for the last 15 years. You also say that you were not aware of any requirements that the treating provider had to 
be a Plan approved provider. The Plan denied your request. The Plan says the treating provider is non-
participating with the Plan and is not a part of the Plan's vendor network. The Plan also says that hearing aids 
ordered through providers that are not Plan approved are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through a Plan-approved hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5298) provided on November 15, 2021 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthoses and suspension sleeves. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have a recent injury or instability. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses are only covered under certain 
medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has end stage osteoarthritis of the knees with loss of the joint space. There is 
no documentation that the enrollee meets the criteria for the requested orthoses. The provided records do not 
document a recent injury to or a surgical procedure on the knees. Knee instability has not been documented by 
examination of the enrollee with objective description of joint laxity as required. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee orthoses and suspension sleeves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this wheelchair is 
medically necessary. The Plan denied your request. The Plan says this device is not covered when used in a 
SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over the counter (OTC) COVID-19 tests purchased from 
January 4, 2022, to January 12, 2022. 
 
You asked the Plan to pay for the OTC COVID-19 tests. You say that you would like to appeal the Plan's 
decision. The Plan denied your request. The Plan says over the counter (OTC) COVID-19 tests purchased 
before January 15, 2022, are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that starting January 15, 2022, most people with a 
health plan can go online, or to a pharmacy or store to purchase an at-home over the counter COVID-19 
diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no cost. Therefore, we decided 
that the Plan does not have to pay for the over the counter (OTC) COVID-19 tests purchased from January 4, 
2022, to January 12, 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 this is medically necessary due to member not being 
able to walk without assistance. The Plan denied your request. The Plan says y it does not appear that criteria 
for approval of inpatient rehabilitation hospitalization per Medicare Benefit Policy are met as documentation 
does not appear to support requirement of physician supervision by a rehabilitation physician making face to 
face visits at least 3 times per week. 
 
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 there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy provided in an inpatient rehabilitation facility, 
specifically with regards to being able to tolerate at least three hours of intensive therapy per day, five days per 
week. The documentation indicates that the patient has limited ability to participate in therapy due to his 
impaired respiratory status and it is not clear if he can tolerate this level of intensive therapy. 
 
Therefore, the request for acute inpatient rehabilitation is considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on June 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says services provided by an out-of-network provider are not covered 
without approved 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 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 outpatient services provided on June 17, 2021, by 
an out-of-network (OON) provider.
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 requires interdisciplinary therapy care 
(occupational therapy, physical therapy). The Plan denied your request. The Plan says based on Medicare 
guidelines and the information they have about your condition; you do not meet the requirements. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee would like to avoid opiate 
medications. The Plan denied your request. The Plan says this is not a treatment of last resort. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain 
medical indications.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. He takes ibuprofen and Tylenol for pain. He has 
had physical therapy, nerve blocks and prior ablations. He has not had spine surgery or a surgical consultation. 
He does not have an evidence-based indication for a SCS trial. Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording for more than 7 
days (93247) provided on February 8, 2021. 
 
You asked the Plan to pay for the physician service. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the external electrocardiographic recording for more than 7 
days (93247) provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #14 provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown. You say that a crown is medically necessary. The Plan denied your 
request. The Plan says a crown is not medically necessary. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that a 
crown is not medically necessary. Our physician reviewer found the amount of structural damage of tooth #14 
is insufficient to warrant a full crown restoration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #14 provided by a participating provider.
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 will clearly benefit from acute 
rehabilitation to optimize her level of functioning prior to returning home. You also say that the enrollee 
requires interdisciplinary therapy care (occupational therapy, physical therapy). The Plan denied your request. 
The Plan says the reason for denial is lack of medical necessity. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy 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.