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 needs to regain prior level of 
functioning. The Plan denied your request. The Plan says the enrollee has not completed the full course in the 
hospital. 
 
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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID-
19. 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory 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 provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on August 11, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve overdenture - complete mandibular (D5865) and 
overdenture - partial mandibular (D5866). 
 
You asked the Plan to pre-approve overdenture - complete mandibular and overdenture - partial mandibular. 
You say that you would like the Plan to fully cover these services based on the dental benefit from previous 
years. The Plan denied your request. The Plan says this service is not covered under the member's benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
overdenture - complete mandibular (D5865) and overdenture - partial mandibular (D5866).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on October 7, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician 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 provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on October 7, 
2020 by an out of network (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's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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 do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient's medical status currently does not 
require intensive physician and nursing supervision in an IRF. The patient is at baseline renal function and 
stable respiratory status. His chronic medical conditions currently do not need intensive IRF monitoring. While 
the patient may benefit from additional physical and occupational therapy the documentation does not support 
that he requires or can fully tolerate this therapy on an IRF level. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from August 3, 
2020 through August 20, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you received a letter saying 
copayments will be waived. The Plan denied your request. The Plan says the copayments 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 $20 
copayment for each Medicare-covered physical, occupational, or speech language therapy visit. 
 
You have been asked to pay a total of $142.74, which is less than the standard $180 for 8 physical therapy 
visits. Physical therapy falls within the "Outpatient rehabilitation 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 copayment for physical therapy provided from August 3, 2020 through August 20, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laparoscopic sleeve gastrectomy (43775). 
 
You asked the Plan to pre-approve this service. You say that weight loss surgery is medically necessary. The 
Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage of this procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover laparoscopic sleeve gastrectomy 
(LSG) for enrollees who have:  
 
(1) a body-mass index (BMI) ; 35 kg/m2, 
 
(2) at least one co-morbidity related to obesity, and 
 
(3) previously have been unsuccessful with medical treatment for obesity. 
 
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 this service. Our reviewer says that a 
laparoscopic sleeve gastrectomy is medically necessary. Our physician reviewer found that you meet the 
Medicare BMI requirement for this service and have more than one eligible co-morbid conditions. The medical 
records show that you have failed conservative efforts at weight loss and thus, meet Medicare criteria for the 
requested service. 
 
We looked at the physician's review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a laparoscopic sleeve gastrectomy (43775).  
 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress. 
 
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. Medicare rules say that a powered pressure-reducing air mattress  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 records show that you do not have 
multiple stage II pressure ulcers on the trunk or pelvis that have failed to improve over the past month. You do 
not have multiple stage III or IV pressure ulcers on the trunk or pelvis or a flap or skin graft for a pressure ulcer 
within the past 60 days. The criteria are not met; therefore, the services are not 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 powered pressure-reducing air mattress.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (HCPCS A0429) provided to the 
enrollee on August 3, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was not billed according to CMS billing guidelines. 
 
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 A0429 is "Ambulance service, basic life support, 
emergency transport (bls-emergency)." 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the 
appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. 
Medicare uses another code for reporting services provided under these circumstances. Therefore, we decided 
that the Plan does not have to pay for ambulance services (HCPCS A0429) provided to the enrollee on August 
3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
October 22, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you could have been 
transported by your family. The Plan denied your request. The Plan says that you are responsible for this 
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 a $240 
copayment for per date of service regardless of the number of ground ambulance trips.  
 
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls 
within the ground ambulance trips benefit category. This means that you have been asked to pay less than 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 ambulance transport provided on October 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60mg/ml Prolia (J0897). 
 
You asked the Plan to pre-approve the Prolia. You say that using another bisphosphonate as treatment is not an 
option due to the member's poor treatment with Alendronate. The Plan denied your request. The Plan says the 
member does not meet step therapy exception criteria 
 
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 the Prolia. Our reviewer says that the 
member has not tried and failed an oral bisphosphonate drug and Zoledronic Acid. Our physician reviewer 
found there is no documentation provided indicating that the Plan's required drugs would likely be less 
effective and/or likely 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 the Prolia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 60mg/ml Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided from April 23, 2020 to April 
24, 2020. 
 
You asked the Plan to pay for the physician 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that if more than one evaluation and management service is provided on the same day to the 
same patient by the same physician, only one evaluation and management service may be reported unless the 
evaluation and management services are for unrelated problems. 
 
We looked at the file and Medicare rules. We find that CPT codes 99226 and 99217 are not supported in the 
records. Specifically, the record indicates that evaluation and management services rendered to this member 
have previously been processed and paid for the billed dates of service. Therefore, we decided that the Plan 
does not have to pay for the physician services provided from April 23, 2020 to April 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided 
on July 2, 2020. 
 
You asked the Plan to waive the copay for the CT scan. You say that your account is not subject to a copay 
outside of a doctor's visit. The Plan denied your request. The Plan says a copay is required for the services. 
 
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 $200 
copay for Medicare-covered diagnostic radiology services in an outpatient hospital setting.  
 
You have been asked to pay a $200 copay for the CT scan. The CT scan falls within the outpatient diagnostic 
tests 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 copay for the computed tomography (CT) scan 
provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a thermometer purchased July 26, 2020. 
 
You asked the Plan to pay for the thermometer. You say that the thermometer should be covered. The Plan 
denied your request. The Plan says the over-the-counter benefit was exhausted at the time this item was 
purchased. 
 
The Plan must follow Medicare rules. Medicare does not cover this item. The plan's rules apply in this case. 
The plan provides coverage for over-the-counter items up to $315 per quarter. This benefit does not carry over 
to the next year.  
 
We looked at the file, the plan's rules, and Medicare rules. The enrollee was reimbursed for $553 for the 3rd 
quarter. The benefit for over-the-counter items was exhausted at the time this item was purchased. Based on 
this information, we decided that Medicare rules for coverage of the thermometer have not been met. 
Therefore, we decided that the Plan does not have to pay for a thermometer purchased July 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection for a power wheelchair 
(E2310) for the enrollee. 
 
You asked the Plan to pre-approve this item. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is not a medical need to control this power option through the joystick. 
 
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 this item. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. The patient has sufficient 
strength in the left upper extremity and functional ability to operate any power options through their own 
individual switches. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for this 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 this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electronic connection for a power wheelchair (E2310) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide reimbursement for the return transportation from a liver transplant 
center provided on July 10, 2020. 
 
You asked the Plan to provide reimbursement for the transportation. You say that you were reimbursed for the 
trip going to this hospital so you do not understand why the trip back would be denied. The Plan denied your 
request. The Plan says that since this authorization was NON-TRAN, this transportation cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There is insufficient information in the file to determine whether the Plan's 
denial of payment is correct. The Plan states this cannot be paid because the authorization was non-transplant 
related. No evidence of this was provided. You were seen at a distant location for care related to a liver 
transplant. This is documented in the discharge summary you provided. The Plan did not request any records 
and did not show a copy of the authorization which they referenced. Without this information, we find that the 
denial of payment is not supported. Therefore, we decided that the Plan has to provide reimbursement for the 
return transportation from a liver transplant center provided on July 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an infusion insulin pump (E0784) and continuous 
glucose monitor supplies (A9277, A9276). 
 
You asked the Plan to pre-approve an infusion insulin pump and continuous glucose monitor supplies. You say 
that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that administration of continuous subcutaneous 
insulin for the treatment of diabetes mellitus is covered if either the enrollee has a fasting blood sugar obtained 
at the same time as the C-peptide level is less than or equal to 225 mg/dl or a Beta cell autoantibody test is 
positive. The rules also say that codes A9276 and A9277 describe the supplies used with a non-therapeutic 
CGM and will be denied as non-covered (no benefit). 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. The record does not show that the enrollee has a fasting blood sugar 
obtained at the same time as the C-peptide level is less than or equal to 225 mg/dl or that a Beta cell 
autoantibody test is positive. Based on this information, we decided that Medicare rules for coverage of an 
infusion insulin pump and continuous glucose monitor supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an infusion insulin pump (E0784) and continuous glucose monitor 
supplies (A9277, A9276).