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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 enrollee does not require intensive rehabilitation services to address the ability to 
transfer at supervision level, walk at minimum assist level and climb stairs at contact guard assist level. The 
enrollee's dementia impairs his ability to participate in and benefit from intensive rehabilitation. 
 
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 IRF admission and services.
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 you are requesting an expedited reconsideration 
stating the enrollee meets all applicable Medicare criteria for admission to an acute rehabilitation unit. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval. 
 
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 enrollee has modest functional impairment following an acute hospitalization for 
acute exacerbation of chronic illness. The enrollee does not require frequent physiatry oversight. Based on their 
current functional status, the enrollee does not require intensive rehabilitation 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 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 specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a specialist visit. You say that you want to see this provider because you are 
sick. The Plan denied your request. The Plan says there are many in-network providers who are available to 
you, who are in the allowed Medicare mileage distance from your residence. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided 
that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), comprehensive oral evaluation 
(D0150), and the intraoral-complete series of radiographic images (D0210) provided on January 25, 2023. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider.   
 
 
Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), comprehensive oral 
evaluation (D0150), and the intraoral-complete series of radiographic images (D0210) provided on January 25, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, bitewing x-rays, and 
cleaning (D1110, D0150, D0274) provided on November 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation, bitewing x-rays, and cleaning (D1110, D0150, D0274) provided on 
November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an influenza virus test provided on January 13, 2023. 
 
You asked the Plan to pay for an influenza virus test. You say that you could not get in to see your primary care 
provider (PCP). 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 an influenza virus test 
provided on January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on 
November 11, 2022. 
 You asked the Plan to pay for the automatic external defibrillator. You say that you were the sole provider of 
this life saving device. The Plan denied your request. The Plan says the device was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that wearable defibrillators are covered for 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 pay for the automatic external defibrillator. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee had 
an echocardiogram in October of 2022 following a motor vehicle accident, showing an ejection fraction of 
25%, with no dilated cardiomyopathy. The wearable defibrillator is a vest like device worn under the clothing 
that continuously monitors the heart rhythm and automatically delivers an electric shock when ventricular 
fibrillation (VF) or ventricular tachycardia (VT) is detected. This device is intended to be worn continuously, 
24-hours per day, except when the wearer is bathing or showering. As such, it would not appear that the 
enrollee was a candidate for a wearable defibrillator or that one was medically necessary for the enrollee's 
clinical management. 
 
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 automatic external defibrillator have not been met. Therefore, we decided 
that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on November 11, 
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 you need rehab to get stronger and walk again. The 
Plan denied your request. The Plan says the services that you need can be provided in an alternate setting such 
as a skilled nursing facility. 
 
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 that you do not require treatment by multiple therapies. You continue to have a need 
for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation 
facility. You 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on February 14, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. 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 nursing facility care 
provided on February 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urine polymerase chain reaction (PCR) panel (87150, 
87481, 87798, 87801) provided on October 26, 2022. 
 
You asked the Plan to pre-approve the urine PCR panel. The Plan denied your request. The Plan says the 
standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The 
PCR testing is considered unproven and not medically necessary. 
 
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 urine PCR panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that PCR testing was medically reasonable 
and necessary, as opposed to urine culture and sensitivity. 
 
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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a urine polymerase chain reaction (PCR) panel (87150, 87481, 87798, 87801) 
provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 25, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that this visit was 
unnecessary. 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 $35 
copayment for in-network specialty care physician office visits. 
 
You have been asked to pay a $35 copayment for a specialist visit. This item/service falls within the in-network 
specialty care physician office visits benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
specialist visit provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 7, 2022, to December 
21, 2022. 
 
You asked the Plan to pay for dental services. You say that you were referred to a specialist because your 
provider could not proceed with your issues. You say that all your services should be covered in full by your 
insurance. The Plan denied your request. The Plan says the services are not covered under your Plan. 
 
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. D0180, D9248, D7953, 
D4267, D7950 and D4266 are not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0180, D9248, D7953, 
D4267, D7950 and D4266 are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for dental services provided on December 7, 2022, to December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic image (D0220) and the 
crown (D2750) for tooth #17 provided on January 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the denial for the calendar year maximum 
being met is not reasonable because your coverage just started. The Plan denied your request. The Plan says 
your yearly combined dental allowance benefit for the year 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 on January 11, 2023, the Plan paid $328 for dental services. On January 18, 2023, the Plan paid $922 for 
dental services. For the year of 2023 the Plan paid $1,250 ($328 paid + $922 paid) for dental services; 
therefore, your annual maximum benefit for the year of 2023 was exhausted on the date of service of January 
18, 2023. Therefore, we decided that the Plan does not have to pay more for the intraoral radiographic image 
(D0220) and the crown (D2750) for tooth #17 provided on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) services. 
 
You asked the Plan to pre-approve the CTA services. You say that the requested CTA services are needed 
because the enrollee has an aneurysm of the ascending aorta. The Plan denied your request. The Plan says a 
CTA is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA services. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee has no record of an 
abdominal ultrasound study. The clinical documentation provided does not support the medical necessity of a 
CTA in the enrollee's clinical management. 
 
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 CTA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve computed tomography angiography (CTA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
thoracic surgeon. 
 
You asked the Plan to pre-approve a continuation of care with an OON thoracic surgeon. You say that you are 
requesting a continuum of care because all of the enrollee's surgery testing and procedures were done at the 
OON facility that the requested OON provider works from. The Plan denied your request. The Plan says there 
are providers within the network who are able to treat the enrollee. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continuation of care with an OON 
thoracic surgeon. Our reviewer says that the criteria for coverage of OON care have not been met. Our 
physician reviewer found the enrollee is not currently receiving any active treatment and/or medical 
management of her condition that would make it medically necessary to continue care with the OON provider 
as requested. There is nothing unique about the enrollee's condition that would make it medically necessary for 
her to continue care with the requested OON provider. The Plan has shown that they have in-network 
specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care 
required for treatment of the enrollee's condition. The enrollee's medical management and/or follow-up care 
can be safely transitioned to an in-network specialist 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 a continuation of care with an OON thoracic surgeon have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out-of-network 
(OON) thoracic surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TaqPath COVID-19 test (87636) provided on January 29, 
2023. 
 
You asked the Plan to pay for the TaqPath COVID-19 test. You say that this test was medically necessary and 
is supported in the medical record. 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 the TaqPath COVID-
19 test have not been met. Therefore, we decided that the Plan does not have to pay for the TaqPath COVID-19 
test (87636) provided on January 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrophysiological procedures to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON electrophysiological procedures. You say that these services are 
necessary and were recommended by the enrollee's physician. The Plan denied your request. The Plan says the 
requested provider in this case is not part of the Plan's network. There are in-network providers available who 
can perform the requested care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
electrophysiological procedures to be provided by an out-of-network (OON) provider.