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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
22, 2023. 
 You asked the Plan to pre-approve SNF care after June 22, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
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 SNF care after June 22, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) 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 SNF care after June 22, 2023, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management service provided on January 
07, 2023. 
 
You asked the Plan to pay for the evaluation and management service. You say that the provider is not 
responsible for obtaining 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 the evaluation and 
management service provided on January 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Portable Oxygen Concentrator (POC) (E1392).  
 
You asked the Plan to pre-approve a POC. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 POC Our reviewer says that the 
enrollee does not need this item. Our physician reviewer found there is no documentation in the medical record 
that portable tanks already provided to the enrollee would not meet the enrollee's needs for mobility within the 
home.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a POC have not been met. Specifically, the enrollee already has an oxygen 
concentrator with portable tanks that meets their needs. Therefore, we decided that the Plan does not have to 
pre-approve a Portable Oxygen Concentrator (POC) (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the neurolytic nerve blocks/cryotherapy treatments 
(Iovare). 
 
You asked the Plan to pre-approve the neurolytic nerve blocks/cryotherapy treatments (Iovare). You say that 
this service is medically necessary. The Plan denied your request. The Plan says this is considered 
experimental. 
 
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 the neurolytic nerve blocks/cryotherapy 
treatments (Iovare). Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered experimental. 
 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 neurolytic nerve blocks/cryotherapy treatments (Iovare) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the neurolytic nerve blocks/cryotherapy 
treatments (Iovare).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 3260F billed for date of service 
October 12, 2022.  
 
You asked the Plan to pay for the billed services. You say that the medical records support the units performed. 
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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. Providers must report services with the appropriate code. 
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were justified. We find that 
code 3260F is a measurement code that is used for reporting purposes only. This means the code is not payable. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 88342 and 3260F billed for 
date of service October 12, 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 like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in another setting.  
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The plan has approved ongoing care in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that  you would like reconsideration based on the 
records submitted.  The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trifocal lenses and the anti-reflective lens coating 
provided on February 23, 2023. 
 
You asked the Plan to pay for the trifocal lenses and the anti-reflective lens coating. You say that  the denial 
says that the benefit has been exhausted, but you have not purchased new eyeglasses since May of 2021. The 
Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $300 allowance. 
 
We looked at the file and the Plan's rules. The Plan paid $300 towards the vision items provided on February 
23, 2023, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage 
of the trifocal lenses and the anti-reflective lens coating have not been met. Therefore, we decided that the Plan 
does not have to pay for the trifocal lenses and the anti-reflective lens coating provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  crown for teeth #2, #4 (D6740) and pontic for tooth #3 
(D6245). 
 
You asked the Plan to pre-approve a crown and a pontic. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says  if teeth are missing on both sides of the arch the benefit 
of a fixed bridge in that same arch is limited to the benefit of a partial denture. You are missing teeth on both 
sides of the upper arch. You are missing tooth #3 on the right side and teeth #13, #14 on the left side. 
 
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 and a 
pontic 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 and a pontic. Our reviewer says that the service is not medically necessary. Our physician reviewer found if there are multiple missing 
teeth in both sides of an arch a fixed bridge is not covered. In this case teeth #'s 3, 13 and 14 are missing. The 
replacement of the missing teeth can be accomplished with a removable partial. 
 
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 and a pontic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve  crown for teeth #2, #4 (D6740) and pontic for tooth #3 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments (D9630) provided on November 
29, 2022. 
 
You asked the Plan to pay for the dental service. You say that you provided more information so the Plan can 
pay for the dental services. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because the drugs or medicaments is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the drugs 
or medicaments (D9630) provided on November 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the debridement procedure provided on 
February 03, 2023. 
 
You asked the Plan to reduce the copayment for the debridement procedure. You say that you were only 
charged a $25 copayment last time. 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 $295 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $295 copayment for the debridement procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for the debridement procedure provided on February 03, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L1 kyphoplasty. 
 
You asked the Plan to pre-approve the L1 kyphoplasty. You say that you have been in pain for months. The 
Plan denied your request. The Plan says the L1 kyphoplasty was not medically necessary due to multi-factorial 
pain with multi-level disc disease in the lower thoracic spine and retropulsion of bone fragments. 
 
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 the L1 kyphoplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were being treated for a fracture of a lumbar vertebra with severe, chronic low 
back pain. The computed tomography (CT) scan noted the compression fracture at L1 has progressed 
significantly since May 5, 2023, and therefore acute, currently with a 40% loss of height of the body of L1. The current low back pain is multifactorial. However, less invasive treatments have not been documented to have 
been tried and failed. There is no compelling rationale is presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested kyphoplasty at L1, in 
this case, 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 L1 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the L1 kyphoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on April 22, 2022, through 
August 3, 2022.  
 
You asked the Plan to pay for the psychotherapy services. You say that the other insurance company should not 
have been listed as primary. You say that the Plan in this case approved the 53 sessions for one year. You say 
that you are confused.  The Plan denied your request. The Plan says they need to see explanations of benefits 
from the primary insurer as evidence of the claims having been submitted to them first. The Plan says that your 
coordination of benefits has been updated on February 2, 2023, and that they are now your primary insurer, but 
that on the dates of service in dispute they were your secondary insurer 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you 
and the provider to send the bills to the primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the psychotherapy services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on April 22, 
2022, through August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 16, 2023. 
 
You asked the Plan to pay for office visit. You say that you believe the services are medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
January 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
February 19, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the emergency 
room did not provide care. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room services. This item/service falls within 
the emergency 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 the emergency room 
services provided on February 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on January 27, 2023. 
 
You asked the Plan to pay for a portable chest x-ray. You say that this provider is a Medicare certified 
provider. 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 a portable chest x-ray 
provided on January 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for positron emission tomography (PET) scan provided on 
December 07, 2022. 
 
You asked the Plan to pay for positron emission tomography (PET) scan. 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 positron emission 
tomography (PET) scan provided on December 07, 2022.