Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
September 6, 2022, and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that the 
continuation of inpatient mental health care from September 6, 2022, and forward is medically necessary. The 
Plan denied your request. The Plan says the continuation of inpatient mental health care from September 6, 
2022, and forward is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 continuation of inpatient mental 
health care. Our reviewer says that the continuation of inpatient mental health care from September 6, 2022, 
and forward is not medically necessary. Our physician reviewer found this enrollee did not require inpatient 
mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
I am unable to find an individualized treatment plan however the entire record is not present. It appears that the 
services were supervised and evaluated by a physician. Based upon review of the records provided, this 
enrollee does not meet the criteria for treatment in an acute inpatient mental health facility beyond the date in 
question of September 6, 2022 and forward and could have been treated in a lesser restrictive setting as he was 
not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not 
showing any behaviors or aggression and was being cooperative and compliant while not showing any acute 
threats to safety. 
 
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 continuation of inpatient mental health care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
September 6, 2022, and forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic on tooth #7 (D6245) provided on April 6, 2022. 
 
You asked the Plan to pay for a pontic. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says a pontic (D6245) is not covered by your supplemental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic 
on tooth #7 (D6245) provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair (K0814) provided June 17, 2021. 
 
You asked the Plan to pay for the power wheelchair. You say that the power wheelchair was medically 
necessary. The Plan denied your request. The Plan says the provider does not participate in the Medicare 
program and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a power wheelchair (K0814) provided 
June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CPAP Cushion (A7032) provided on January 18, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CPAP Cushion. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they were 
provided out-of-network by a provider who is not certified for Medicare. 
 
 
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 a CPAP Cushion (A7032) provided on January 18, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on December 6, 2021. 
 
You asked the Plan to pay for acupuncture. You say that acupuncture was medically necessary. The Plan 
denied your request. The Plan says a licensed acupuncturist is a non-covered provider type and the provider is 
not supervised by any physician, physician assistant, nurse practitioner or a clinical nurse specialist.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided on 
December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is no documentation of a second set of diagnostic MBBs. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no second 
set of diagnostic MBBs documented as required. Our physician reviewer found that your condition does not 
meet criteria for coverage of these services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wellness visit (G0439) provided on October 7, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wellness visit. You say that the services should be covered as you disagree 
with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as they were non-emergent and prior 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a wellness visit (G0439) provided on October 7, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genetic testing billed with codes 81406, 81408, 
88341, 88342, and 88360. 
 
You asked the Plan to pre-approve the genetic testing billed. You say that your physician requested the testing. 
The Plan denied your request. The Plan says they approved the genetic testing for 51 or greater genes and the 
additional diagnostic testing was denied because it represents unbundling of codes. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
  We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the genetic testing billed 
with codes 81406, 81408, 88341, 88342, and 88360.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472) 
 
You asked the Plan to pre-approve the removal of torus palatinus. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they do not fall within 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of torus palatinus (D7472)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on April 12, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you are being financially impacted by this expense 
because you paid out of your limited funds, and would like the Plan to reimburse you. The Plan denied your 
request. The Plan says you obtained these hearing aids through an OON 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 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided on April 12, 
2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoe equipment (A5500, A5512) provided on 
February 24, 2022. 
 
You asked the Plan to pay for the diabetic shoe equipment. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says they have reached out to the 
ordering provider and confirmed they did not sign the prescription for diabetic shoes. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the medical records do not confirm that the ordering provider discussed the need for the ordered equipment with the enrollee. Therefore, we decided that the Plan does not have to pay for the 
diabetic shoe equipment (A5500, A5512) provided on February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with lower extremity cellulitis and osteitis of the heel. The record indicates that the enrollee has 
had a complicated hospital course, including hypotension and anasarca. The record indicates that the enrollee 
still requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0673) provided on 
October 7, 2021. 
 
 
 You asked the Plan to pay for a pneumatic compression device. You say that you do not agree with the denial 
for place of treatment and are asking the Plan to reconsider because the segmental gradient pressure pneumatic 
appliance was provided to the enrollee in an ambulatory surgical center and removed before discharge. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare when the 
place of service is an ambulatory surgical center. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a pneumatic compression device have not been met. Specifically, this claim was billed with a POS 
code in an ambulatory surgical center, therefore, it is not a covered benefit. Therefore, we decided that the Plan 
does not have to pay for a pneumatic compression device (E0673) provided on October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 
5, 2022, to April 11, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that both stays should be considered 
a single stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $335 per 
day for days 1-6 and $0 per day after day 6 for each inpatient stay.  
 
The file shows that you were in the hospital from April 5, 2022, to April 11, 2022. Therefore, you have been 
asked to pay $335 per day for days 1-6 of inpatient care. The total for your stay is $2,010 ($335 copayment x 6 days = $2,010). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from April 5, 2022, to April 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you do not agree with the denial and are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says prior authorization was not 
obtained by the provider or facility. The provider should have verified the enrollee's eligibility, health benefits 
and obtained authorization prior to the visit before providing services to the enrollee. 
 
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 an office visit provided on March 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR (polymerase chain reaction) testing (87798, 
87481, 87640 and 87653) provided on January 21, 2022. 
 
You asked the Plan to pay for urine PCR testing. You say that these services were reported correctly and were 
medically necessary. The Plan denied your request. The Plan says these services are considered unproven and 
are not medically necessary. Generally, a urine culture and sensitivity with urinalysis is the standard of care for 
evaluation of urinary incontinence. 
 
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 pay for urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a urine PCR test was performed to look for pathogens prior to an exchange of indwelling ureteral stents. The enrollee was not experiencing pain, nausea, vomiting, fever or chills. The standard of care 
is to perform a urine culture with urinalysis for this clinical situation, and PCR testing has insufficient high-
quality studies to support that it is superior to the current standard in terms of overall outcomes to support this 
request. Therefore, the urine PCR testing will be 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 urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR (polymerase chain reaction) testing (87798, 87481, 87640 and 87653) provided 
on January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller E2377, harness E2313 and 
electronic connection between wheelchair controller and two or more power seating system motors E2311 
 
You asked the Plan to pre-approve upgraded electronics. You say that the enrollee has a history of traumatic 
spinal cord injury. Due to this the enrollee is being prescribed a group 3 power wheelchair with multiple power 
seating options. The Plan denied your request. The Plan says the upgraded electronics are not medically 
necessary. The approved power options come with their own switches. 
 
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 upgraded electronics. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollee has a neurologic disorder with functional deficits. Criteria for a power wheelchair are met. The requested electrical accessories are not medically necessary as the enrollee 
does have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the expandable controller E2377, harness E2313 and electronic connection 
between wheelchair controller and two or more power seating system motors E2311