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

We decided that the Plan does not have to pre-approveadditional routine transportation.You asked the Plan to pre-approveadditional transportation. You say that transportation is a necessity.The Plan denied your request. The Plan says you have exhausted your routine transportation benefit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on the information provided, we decided that you have exhausted the Plan'smaximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that this is necessary to treat the enrollee's anemia. The 
Plan denied your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
criteria for coverage of Aranesp have not been met. Our physician reviewer found the Plan requires a trial of 
Retacrit before they will approve the requested drug. Based on the medical records provided, the enrollee has 
not tried Retacrit and there is no indication that Retacrit would likely be less effective or have adverse effects 
for the enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
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 continuation of medically necessary 
acute care services in a LTACH is medically appropriate. The Plan denied your request. The Plan says a 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer 
found that the clinical assessment in the case file does not support that the enrollee is reasonably expected to 
benefit from, and improve with LTACH services that are not available in the acute care hospital. Our physician 
reviewer also found that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build-up for tooth 21.You asked the Plan to pre-approvethese services. You say that the enrollee will require a full crown due to decay in tooth 21.The Plan denied your request. The Plan says the services are not covered.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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build-up for tooth 21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a static progressive stretch device. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
had a fracture to your left elbow that required surgery that caused the elbow to stiffen. The requested device is 
considered experimental/investigational in nature, as there is no peer-reviewed literature to confirm or support 
that it is medically effective. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a static progressive stretch device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that care/treatment can safely and adequately be completed at an alternate 
level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have back pain that does not respond to positioning in an ordinary bed. The documentation does not show that 
you need an immediate change in body position or frequent changes in body position. You do not need special 
attachments that cannot be fixed on an ordinary bed. The requested semi-electric hospital bed is not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a semi-electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom shoes (L3230) provided on December 31, 2019. 
 
You asked the Plan to pay for custom shoes. You say that these shoes are medically necessary. The Plan denied 
your request. The Plan says these items are not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that shoes, inserts, and modifications are covered in 
selected beneficiaries with diabetes for the prevention or treatment of diabetic foot ulcers or if they are an 
integral part of a covered leg brace. 
 
We looked at the file and Medicare rules. The medical records do not show that these shoes were provided for 
the prevention or treatment of diabetic foot ulcers or as an integral part of a covered leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Based on this information, we decided that Medicare rules for coverage of custom shoes have not 
been met. Therefore, we decided that the Plan does not have to pay for custom shoes (L3230) provided on 
December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services (CPT 99291) provided on January 31, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed code is not supported.The Plan must follow Medicare rules. The rules say that critical care is not a service that is paid on a "shift" basis or a "per day" basis. Critical care service is paid on a time-based service provided on an hourly or fraction of an hour basis. For this reason, the documentation provided bythe physician must include the amount of time in hours and minutes that is spent on providing critical care service. In this case, there is no evidence in the medical documentation to show the total time spent delivering critical care to the enrollee. Therefore, we decided that the Plan does not have to pay forthe critical care services (CPT 99291) provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99309) provided on April 16, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you provided medically necessary services in 
good faith. The Plan denied your request. The Plan says non-emergent care must be obtained by an in-network 
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 has network providers 
available who can provide 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 the nursing facility care (99309) provided on April 
16, 2020 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 surgical placement of implant body: endosteal implant 
and prophylaxis provided on September 23, 2019, and December 18, 2019. 
 
You asked the Plan to pay for the endosteal implant and prophylaxis. You say that you did not use the total 
benefit allowed for dental services in 2019. The Plan denied your request. The Plan says implant services are 
not one of the covered categories of dental services. The Plan also says that you exceeded the maximum 
number of cleanings allowed for the given time period. 
 
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, surgical placement of implant body: 
endosteal implant is not among those covered under this benefit. The contract also clearly states that cleanings 
are limited to two visits every year. The record shows that you received prophylaxis cleanings on April 23, 
2019, and August 20, 2019, and your cleanings benefit had been exhausted. Therefore, we decided that the Plan 
does not have to pay for the surgical placement of implant body: endosteal implant and prophylaxis provided 
on September 23, 2019, and December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit provided on April 14, 2020.You asked the Plan to waive the copayment fora specialist office visit. You say that this was a follow up visit and should be covered.The Plan denied your request. The Plan says the copayment you are being charged is correct.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 $45 copayment for each Medicare-covered specialist office visit. You have been asked to pay $44.08 for a specialist office visit, which is less than your copaymentamount. A specialist office visit falls within the physician/practitioner services, including doctor's 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 fora specialist office visit provided on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on February 12, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you visited your son in Chicago and realized you 
lost your medications. You went to a medical clinic that day and only had to pay $10 for the consult and now 
you receive an invoice for $99. The Plan denied your request. The Plan says enrollee's must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 has network providers 
available who can provide 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 the outpatient office visit provided on February 
12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the office visit (99214) 
provided on May 18, 2020. 
 
You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the claim has 
been processed appropriately with a zero member liability. 
 
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 $5 
copayment for provider and professional services provided at a PCP's office.  
 
You have been asked to pay a $0 copayment for the provider services rendered at your PCP's office. The Plan 
contract states there will be a $5 copayment for primary care visits, however, the Plan is waiving the cost share 
for all visits to your primary care physician for the year 2020. The Plan contacted your provider who agreed to 
issue reimbursement of the copayment paid at the time of service. 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 issue 
reimbursement of the copayment for the office visit (99214) provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve these services. You say that you need the CPAP to breathe. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that continued CPAP use is covered when specific 
criteria are met. 
 
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 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). The compliance 
summary from June 23, 2020 to September 20, 2020 does not meet the minimum usage criteria. You have used 
the device four hours per day for 44.4 percent of the days. The lack of usage has not been addressed clinically. 
The continued CPAP is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound therapy pump and supplies you 
received on January 2, 2020. 
 
You asked the Plan to waive the coinsurance for the wound therapy pump and supplies. You say that all of 
these items should be provided with no copayment because you were getting home health care. The Plan 
denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the wound therapy pump and supplies. The wound therapy 
pump and supplies fall within the durable medical equipment and related supplies benefit category. These items 
are not part of the home health benefit category because they were provided by a durable medical equipment 
company, not a home health agency. 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 coinsurance for the wound therapy 
pump and supplies you received on January 2, 2020.