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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are being discharged from the hospital and there 
is no one to care for you at home. You say it could cause your progress to decline. The Plan denied your 
request. The Plan says based on Medicare guidelines, 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 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on September 09, 2022, to 
September 24, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was 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 the nursing facility care 
provided on September 09, 2022, to September 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs or non-routine services for durable medical 
equipment (DME) (K0739 x14), shock absorber for power wheelchair (E1016), caster fork (E2396 x4), solid 
caster tire (E2392 x4), front suspension replacement (K0108), rear suspension (K0108), and drive wheel color 
insert (K0108). 
 
You asked the Plan to pre-approve repairs or non-routine services for a power wheelchair. You say that the 
repairs are necessary. The Plan denied your request. The Plan says Medicare does not cover repairs when the 
expense for repairs exceeds the estimated expense for replacement of the wheelchair. The Plan also says the 
drive wheel color is not typically covered for the enrollee's specific plan. 
 
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 repairs or non-routine services for a 
power wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found Medicare covers repairs when repair is less than 
replacement. The wheelchair is eligible for replacement and costs exceed cost of replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repairs or non-routine services for a power wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve repairs or non-routine services for durable 
medical equipment (DME) (K0739 x14), shock absorber for power wheelchair (E1016), caster fork (E2396 
x4), solid caster tire (E2392 x4), front suspension replacement (K0108), rear suspension (K0108), and drive 
wheel color insert (K0108).
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for an IRF admission.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement. However, there is no indication that the enrollee would require skilled rehabilitation 
in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at 
least 3 visits weekly to regain or maintain her functional status. The enrollee can receive further services at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0326U provided on May 30, 2023. 
 
You asked the Plan to pay for procedure code 0326U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0326U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0326U 
provided on May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 provided on April 27, 2023. 
 
You asked the Plan to pay for procedure code G0481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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, the CPT Code Manual definition of code G0481 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records show that more 
than 14 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0481 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0481 provided on April 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee cannot function on their own. The Plan 
denied your request. The Plan says the enrollee is receiving adequate and necessary care in the inpatient 
rehabilitation facility (IRF). 
 
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 clinical documentation shows that enrollee has had clinical and functional status 
change thus would be expected to require continued assessment by skilled therapy and skilled nursing. The 
clinical documentation shows that the enrollee's past level of function was modified independent with mobility 
and self-care tasks currently requiring supervision to minimal assist with self-care and mobility tasks with 
intensive therapy. The clinical documentation shows that the enrollee requires frequent nursing assessment thus 
daily services are supported. However, from a practical standpoint, the clinical documentation shows that the 
enrollee is benefitting and requires intensive therapy, close medical monitoring and frequent rehabilitation 
nurse assessment which a SNF does not provide. Therefore, a SNF stay is not medically appropriate. 
 
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 skilled nursing facility (SNF) care.
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 care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 dental services provided on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says your annual dental allowance amount has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $2,000 dental allowance amount was exhausted on date of service May 19, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on June 26, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 82310, 83036, and 83970 provided on June 21, 2023. 
 
You asked the Plan to pay for procedure codes 82310, 83036, and 83970. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment for code 82310 as being inclusive in 
the payment for code 80053; however, the Plan has not provided a claim that shows code 80053 was paid. 
Additionally, the Plan did not make an appeal decision for codes 83036 and 83970. The Plan is not allowed to 
reopen any determinations while an appeal is pending and must issue a determination on all appealed services 
within the appeal time frame. As the Plan forfeited its opportunity to provide a denial rationale for these 
services, we find that the denial of payment is not supported for codes 83036 and 83970. Therefore, we decided 
that the Plan has to pay for procedure codes 82310, 83036, and 83970 provided on June 21, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on June 5, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that you spoke with a Plan representative regarding 
a hearing aid for the enrollee. You also say the representative assured you that the rendering provider is an in-
network provider. The Plan denied your request. The Plan says there is no coverage for hearing aids when 
received from a provider other than the Plan hearing network provider. 
 
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 the hearing aids are obtained through a Plan hearing network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on June 5, 2023.
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 needs an IRF admission to assist her in 
gaining her independence. The Plan denied your request. The Plan says an IRF admission is not reasonable and 
necessary for the enrollee.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation does not support that she would meet criteria for admission to an acute inpatient rehabilitation 
facility. The enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network office visit with an 
electrocardiogram (EKG) provided on May 24, 2023. 
 
You asked the Plan to waive the copayment for an office visit and EKG. You say that this was supposed to be a 
routine visit, you should not owe anything. 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 an $85 
copayment for each covered diagnostic procedure or test at a network doctor's office, and a $10 copayment for 
each covered primary care provider (PCP) office visit. You have been asked to pay the allowed amount of 
$13.45 which is less than the $85 copayment for an EKG. Your total is $23.45 ($13.45 + $10 = $23.45).  You have been asked to pay a $23.45 total copayment for an office visit and EKG. This item/service falls 
within the for each covered diagnostic procedure or test at a network doctor's office and each covered primary 
care provider (PCP) office visit 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 in-network office visit with an electrocardiogram (EKG) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown (D2954), 
the treatment of root canal obstruction (D3331), unspecified endodontic procedure (D3999) and endodontic 
therapy (D3310) provided on July 7, 2022. 
 
You asked the Plan to pay for a prefabricated post and core in addition to crown (D2954), the treatment of root 
canal obstruction (D3331), unspecified endodontic procedure (D3999) and endodontic therapy (D3310). You 
say that you went into the office on an emergency visit. You also say that you were referred to another 
provider. The Plan denied your request. The Plan says there is no coverage for these services. 
 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 
prefabricated post and core in addition to crown (D2954), the treatment of root canal obstruction (D3331), 
unspecified endodontic procedure (D3999) and endodontic therapy (D3310) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided on July 31, 2023.  
You asked the Plan to pay for polycarbonate lenses (V2784). You say that you have not gotten eyeglasses for 
three years and have not used the benefit. You also say that $200 should be applied to the benefit for eyewear. 
The Plan denied your request. The Plan says the submitted claim for eyewear paid the $100 eyewear allowance, 
thus exhausting the eyewear benefit. 
 
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 up to $100 towards the reimbursement towards the purchase of eyeglasses or contact 
lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that you receive a $100 allowance per calendar 
year towards routine eyewear. Based on this information, we decided that the Plan's rules for coverage of 
polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not have to pay for 
polycarbonate lenses (V2784) provided on July 31, 2023.