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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 there are no services at the LTACH that the patient requires that are not already 
available and covered at the current location. Transfer to a lower level of care may be considered soon. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that it is painful for you to use crutches. The Plan 
denied your request. The Plan says there is a lack of published clinical literature demonstrating safety and 
effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simbrinza. 
 
You asked the Plan to pre-approve Simbrinza. You say that the enrollee has been on this medication for months 
and their intraocular pressure has been acceptable. The Plan denied your request. The Plan says this drug is not 
covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Simbrinza.  
 
Benefits for Simbrinza may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient mental health services you 
received from June 17, 2020, to June 30, 2020. 
 
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you are on a 
fixed income and cannot afford this amount. The Plan denied your request. The Plan says you were charged 
this copayment 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 $390 
copayment per day for days 1-4, and $0 for days 5-90 for inpatient mental health care.  
 
You have been asked to pay a $390 copayment per day for days 1-4, (for a total of $1,560) for the inpatient 
mental health services. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient mental health services 
you received from June 17, 2020, to June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested item is not considered medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 vehicle. Our reviewer says that the 
requested vehicle is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal a personal mobility deficit that impairs participation in MRADLs in the home. Your deficit is 
currently helped by a cane. The documentation does not support that this device would significantly improve 
participation in MRADLs in 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 the vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan of extremity veins provided February 10, 
2020. 
 
You asked the Plan to pay for the duplex scan of extremity veins. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
   
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a duplex scan of extremity veins provided February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift chair and associated costs provided on May 28, 
2020. 
 
You asked the Plan to pay for these services. You say that this was medically necessary for you. The Plan 
denied your request. The Plan says that the provider must be eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for the seat lift chair and associated costs provided on May 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on December 20, 2019. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you would like the plan to 
reconsider their denial The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that HBO therapy is only covered for certain 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 pre-approve hyperbaric oxygen therapy. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has a history of significant head and neck radiation. 
Currently the enrollee requires extraction of non-resorbable symptomatic teeth #14, 19, 30, and 31 from the 
maxilla and mandible. Per the provider, enrollees with a history of head and neck radiation are at risk of 
radiation osteonecrosis following dental extractions. Medicare guidelines say that this item or service is 
covered to treat multiple conditions including Osteoradionecrosis as an adjunct to conventional treatment and 
The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing 
for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound 
care. In this case, the request is for hyperbaric oxygen therapy as a preventative measure rather than as 
treatment. Therefore, the enrollee does not meet criteria for the requested 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 hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5224). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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-approve an 
immediate mandibular partial denture (D5224).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing services provided from 
June 3, 2020, to June 13, 2020 by an OON provider. 
 
You asked the Plan to waive the copayment for the skilled nursing services. You say that you should not have 
to pay OON benefits because you were not informed that this facility was OON. You also say that you should 
have to pay in-network rates. The Plan denied your request. The Plan says the copayment amount that 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 $750 
deductible before the Plan will pay their share. The contract also clearly states that after meeting the deductible, 
you must pay a 40% coinsurance per day for days 1 to 100 for out-of-network Skilled nursing facility (SNF) 
care. 
 
You have been asked to pay the remainder of your deductible, and a 40% coinsurance per day for days 1 to 100 
for out-of-network skilled nursing facility services for the skilled nursing services. The skilled nursing services 
falls within the Skilled nursing facility (SNF) 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 skilled nursing services provided from June 3, 2020, to June 13, 2020 by an OON provider.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF 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 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. 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 was admitted for surgical repair of a 
hip fracture after a fall. The enrollee's medical conditions are stable. There are medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology office visits to be provided by an out of 
network (OON) provider at in-network benefits exception. 
 
You asked the Plan to pre-approve the office visits. You say that the enrollee had his transplant at this facility 
and you prefer that he remains there to see other specialists so that providers can easily communicate and 
ensure the safety of his transplanted kidney. The Plan denied your request. The Plan says you can receive your 
care from either a network provider or an out-of-network provider. If you use an out-of-network provider, your 
share of the costs for your covered services may be higher. 
 
The plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical 
care as long as the care you receive is considered medically necessary and you receive your care from a 
provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can 
receive your care from either a network provider or an out-of-network provider. If you use an out-of-network 
provider, your share of the costs for your covered services may be higher. 
 
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 an in-network benefit exception. Therefore, we decided that the Plan does not have to 
pre-approve cardiology office visits to be provided by an out of network (OON) provider at in-network benefits 
exception.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ophthalmology visits you had on 
September 26, 2019, and May 8, 2020. 
 
You asked the Plan to waive the copayments for the ophthalmology visits. You say that these visits were 
follow-up visits, so there should be no copayment. The Plan denied your request. The Plan says you were 
charged these copayments 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 per visit for vision care services.  
 
You have been asked to pay a $35 copayment per visit for the ophthalmology visits. Records show that on the 
dates of service in question, you were billed for office visit services (coded as 99211), not just pressure checks. 
Because of that, the ophthalmology visits fall within the vision care services 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 copayments for ophthalmology visits you had on September 26, 2019, and May 8, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vetiflex Implantation. 
 
You asked the Plan to pre-approve Vetiflex Implantation. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested 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 Vetiflex Implantation. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presents with persistent low back pain radiating down the left lower 
extremity with burning and tingling. The enrollee reports pain with extension and resolution of pain with 
flexion. The enrollee has reported imaging evidence of severe neuroforaminal stenosis at L4/5 with sever left 
L4 nerve root. The enrollee has reportedly failed greater than 7 months of conservative treatment.FDA 
indications include implantation of the Superion device at one or two adjacent lumbar levels in enrollees with 
moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. 
The enrollee has severe stenosis at the L4/5 level which would not meet FDA indications. Therefore, the 
enrollee does not meet criteria for the requested 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 Vetiflex Implantation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Vetiflex Implantation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 1, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 22, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician 
services provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the dental services provided on July 6, 
2020. 
 
You asked the Plan to waive the deductible for the dental services. You say that your supplemental dental 
benefit says you pay a $0 copay for each dental visit. The Plan denied your request. The Plan says there is a 
$35 deductible per calendar year for routine dental services. 
 
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, there is a $35 deductible per calendar 
year for routine dental services. This is a contractual obligation you agreed to when you enrolled in the Plan's 
dental coverage. Therefore, we decided that the Plan does not have to waive the deductible for the dental 
services provided on July 6, 2020.