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 enrollee clearly meets Medicare 
criteria for LTACH care. The Plan denied your request. The Plan says LTACH is not needed since the enrollee 
can just stay in the current facility. 
 
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 enrollee is a female who was diagnosed with COVID on October 15, 2020. She 
presented to the ED on October 22, 2020, with increased shortness of breath and required BiPAP for 
respiratory support. Her condition has stabilized and improved with medical therapy. 
 
There is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute 
hospital level of care services and is receiving appropriate care at the present acute care hospital. The review 
indicates that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and treatment of 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on May 13, 2020. 
 
You asked the Plan to pay for the outpatient hospital 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 
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 May 13, 2020.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that your records do not support that you require the special long 
term acute care available at an LTACH or that you will require long-term acute care for more than 25 days. 
 
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. You still 
require acute hospital level of care services and are receiving appropriate care at the present acute care hospital. 
There are no services available at the LTACH that you require that are not available at the health care setting 
being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare 
criteria for LTACH 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided by a non-participating provider on 
June 3, 2020. 
 
You asked the Plan to pay for hearing aids. You say that you could only deduce from your benefit information 
that you would be covered and entitled to the $1,000 benefit for any hearing aid purchased from any 
audiologist in or out-of-network. The Plan denied your request. The Plan says the denial of hearing aid 
reimbursement is correct, because the hearing aids were not obtained from the Plan-participating 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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained from the Plan-participating provider.  
 
We looked at the file and the Plan's rules. These hearing aids were obtained from a provider other than the 
Plan-participating provider. 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 pay for hearing aids provided by a 
non-participating provider on June 3, 2020.  
 
Your complaints regarding the information you received about your plan's benefits as well as the Plan not 
offering you an explanation for denying your claim are considered to be grievances. We do not have the 
jurisdiction to address grievances. Please contact the Plan for more information about your grievances.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper and lower partial denture. 
 
You asked the Plan to pre-approve the upper and lower partial denture. You say that your current dentures are 
causing you pain. You say that you have had them adjusted and they still don't fit. The Plan denied your 
request. The Plan says this service is only allowed one time every 60 months. 
 
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, you also have a maximum benefit of 
one set of dentures every five years. The Plan paid for an upper and lower partial denture provided on October 
16, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
upper and lower partial denture.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for revascularization (37225) provided on March 31, 2020. 
 
You asked the Plan to pay for revascularization. You say that this code is supported. The Plan denied your 
request. The Plan says that this was not billed appropriately. 
 
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 37225 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 
with atherectomy, includes angioplasty within the same vessel, when performed. 
 
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 revascularization. Our reviewers says that 
the use of this code is supported. Our physician reviewer found the documentation does indicate that 
percutaneous endovascular revascularization of the right femoral artery, with atherectomy, was performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization have been met. Therefore, we decided that the Plan has to pay 
for revascularization (37225) provided on March 31, 2020.  
 
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 waive the copayment for ophthalmological services, medical 
examination and evaluation (92012) scanning computerized ophthalmic diagnostic imaging (92133) visual field 
examination (92083) provided June 18, 2020. 
 
You asked the Plan to waive the copayment for the office visit and diagnostic testing. You say that you 
received a bill from your eye specialist visit. Your copay should only be $40. The Plan denied your request. 
The Plan says the claim was processed and the correct copayment was applied per the plan benefits. 
 
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 $50 
copayment for outpatient diagnostic procedures and tests and $40 copayment for each specialist in-person 
office visit.  
 
You have been asked to pay $83 for the office visit and diagnostic testing. The office visit and diagnostic 
testing falls within the Outpatient diagnostic tests and therapeutic services and supplies and 
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 for ophthalmological services, medical 
examination and evaluation (92012) scanning computerized ophthalmic diagnostic imaging (92133) visual field 
examination (92083) provided June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on May 20, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided February 18, 2020. 
 
You asked the Plan to pay for the home health services. You say that please correct claims to be RAPS as this 
was said to be a system error. The Plan denied your request. The Plan says HIPPS code submitted is invalid, 
missing or incomplete. 
 
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 HIPPS code submitted is invalid for the services rendered and required a corrected claim. 
Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we decided that the Plan 
does not have to pay for the home health services provided February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided a participating 
provide on August 19, 2020. 
 
You asked the Plan to waive the copayment for an eye exam. You say that this was supposed to be a routine 
eye exam. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 vision care/eye exam.  
 
You have been asked to pay a $35 copayment for an eye exam. An eye exam falls within the vision care/eye 
exam 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 eye exam provided by a 
participating provider on August 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's complex medical needs are being met in the 
current acute setting at this time. 
 
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. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on April 16, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency procedure for which you 
could not find an in-network physician due to Covid-19. The Plan denied your request. The Plan says the 
services you are requesting are not covered by your mandatory supplemental dental benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, 
they are not covered. Therefore, we decided that the Plan does not have to pay for the dental services provided 
on April 16, 2020, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found you do not have documented in-
home skilled nursing needs. You do not have documented in-home skilled therapy needs. Therefore, ongoing 
home health services (HHS) are not shown to be medically necessary or reasonable. 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care.
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 a semi-electric hospital bed. You say that this is medically necessary. The 
Plan denied your request. The Plan says that documentation does not indicate that you require frequent and 
immediate need for a change in body position to qualify for a semi-electric hospital bed. 
 
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 a semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically reasonable and necessary. The documentation 
does not clearly reveal your condition has failed positioning of the bed in ways not feasible in an ordinary bed 
or why positioning of the bed in other ways is not feasible.  
 
 
The documentation does not support a need for frequent or immediate changes in body position or special 
attachments that cannot be fixed on an ordinary bed. The head of the bed does need to be elevated more than 30 
degrees most of the time due to chronic pulmonary disease. Our physician reviewer found that your condition 
does not meet Medicare criteria for a semi-electric hospital bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on July 20, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you just went for an 
injection. You say that you have never been charged for the visit before, just the injection. The Plan denied 
your request. The Plan says the correct copayment has been applied. 
 
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 physician/practitioner services/specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist office visit. Since specialist services were 
provided, the correct copayment has been applied. A specialist office visit falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided by a participating provider on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lidocaine patches. 
 
You asked the Plan to pre-approve the Lidocaine patches. You say that you have pain due to surgery. The Plan 
denied your request. The Plan says the drug is not covered by Part B. The Plan says that you do not have Part D 
drug coverage through them. 
 
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 Lidocaine patches.  
 
Benefits for the Lidocaine patches may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.