Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for drug therapy provided by a participating 
provider on July 19, 2019, to July 26, 2019. 
 
You asked the Plan to waive the copayment for drug therapy. You say that you do not agree with this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for outpatient diagnostic tests/in-network/radiation therapy.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for drug therapy. The total allowed 
amount is $1,668.14. The total amount you are being asked to pay to pay is $333.63 ($1,668.14 x 20% = 
$333.63. Drug therapy falls within the outpatient diagnostic tests/in-network/radiation therapy 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 drug therapy provided by a participating provider on July 
19, 2019, to July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air mini travel CPAP. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence submitted to show that the enrollee's life is at risk. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say Medicare covers 
DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already 
available to an enrollee, it is not considered reasonable and 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 item. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the Air Mini Travel CPAP is considered not medically necessary, and the denial is upheld. You already have a 
CPAP device with heated humidifier.  Medicare does not cover duplicate durable medical equipment, and the 
requested device is considered a convenience item. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an air mini travel CPAP.
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 member is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
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 patient 
is currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest. The enrollee was 
intubated/ventilated. The enrollee has not yet failed weaning attempts and has not yet received a tracheotomy. 
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on February 7, 
2020. 
 
You asked the Plan to pay for the assistant at surgery services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
provided on February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula. 
 
You asked the Plan to pre-approve the services. You say that you are not eating and have lost about 20 pounds. 
The Plan denied your request. The Plan says the established CMS criteria has not been met. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you do not meet the CMS medical criteria for coverage. The medical records do not show that you have 
a permanent non-function or disease of the structures that normally permit food to reach the small bowel and 
requires tube feeding to provide sufficient nutrients to maintain weight and strength. 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enteral formula.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require this 
transportation to get to an appointment. The Plan denied your request. The Plan says that this request exceeds 
the benefit allowance. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
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 this transfer is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria are not 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 
based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital 
(ACH) for cellulitis, in the setting of thyroid cancer.  The enrollee is not intubated/ventilated.  There is no 
evidence that the enrollee requires services that are not currently available.  As LTACHs and ACHs are 
licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.  
The enrollee can remain at the current ACH until such time no acute services are required.  Medicare criteria 
for transfer are not met. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient services provided from November 
1, 2019, through November 8, 2019. 
 
You asked the Plan to waive the copayment for inpatient services. You say that the cost share is too much. The 
Plan denied your request. The Plan says the copayment was applied 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 $195 
copayment per day (per Medicare-covered stay) for days 1-8, which includes day of admission and day of 
discharge. 
 
You have been asked to pay $195 copayment per day of your inpatient visit. The total amount you are being 
asked to pay is $1,365.00 ($195 x 7 days = $1,365). Inpatient services fall within the Inpatient hospital 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 inpatient services provided from 
November 1, 2019, through November 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require a transfer to the LTACH. 
 
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 currently undergoing treatment at an ACH for sepsis with respiratory 
failure and renal failure. The enrollee is not intubated/ventilated. The enrollee is not a candidate for 
hemodialysis. The enrollee is noted to have a guarded prognosis and is thought to be appropriate for Hospice. 
There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on March 10, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there are in-network providers available 
for these services. 
 
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 physician services provided on March 10, 2020 by 
an out of network (OON) provider.
Appeal type: Other
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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to the LTACH. 
 
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 currently undergoing treatment at an ACH following cardiac arrest, 
resulting in intubation/ventilation. The enrollee has since been extubated and is no longer on a ventilator. There 
is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are 
licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The 
enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long-term care needs. 
 
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 infusion services (S9328) provided July 28, 2020 to August 
24, 2020. 
 
You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this code is not eligible for Medicare payment. 
 
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 CPT code S9328 is not supported in the medical record. Specifically, the CMS National Physician 
Fee Schedule shows this CPT code has a status of "I" which means it is not eligible for Medicare payment. 
Based on this information, we decided that Medicare rules for coverage of the infusion services have not been 
met. Therefore, we decided that the Plan does not have to pay for infusion services (S9328) provided July 28, 
2020 to August 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility care provided from  
July 17, 2020, through July 31, 2020. 
 
You asked the Plan to pay for these 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 inpatient skilled nursing facility care 
provided was 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 pay for the SNF care. Our reviewer says that the 
inpatient skilled nursing facility care provided was not medically necessary. Our physician reviewer found that 
the enrollee did not require skilled nursing or skilled therapy services on a daily basis.  
Additionally, as a practical matter, the enrollee did 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient skilled nursing facility care provided from July 17, 2020, through July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CPAP equipment provided on August 7, 
2020. 
 
You asked the Plan to waive the coinsurance for the CPAP equipment. You say that the new tubing was not 
necessary and you should not have to pay for it. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 Medicare-covered items.  
 
You have been asked to pay $37.46 which is 20% of the allowed amount for the CPAP equipment. The allowed 
amount is $187.30. ($187.30 x 20% = $37.46). The CPAP equipment falls within the ?Durable medical 
equipment (DME) and related supplies? 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 coinsurance 
for the CPAP equipment provided on August 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says endurance training is not skilled therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition, and 
it does not appear that the enrollee's functional level requires the unique skills of a professional therapist to 
safely and effectively provide treatment, that the services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The enrollee has been compliant in a home exercise program. 
The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
 
 
 
 
 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional physical therapy visits for the enrollee.