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 you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was treated in the hospital for diverticulitis and required surgery. The 
enrollee required total assistance for mobility. The enrollee required moderate assistance for transfers. The 
enrollee required maximum assistance for most activities of daily living. 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. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where the enrollee is currently receiving 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 additional home health PT visits. 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 8 additional home health PT visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested 
therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has 
had extensive therapy, has made progress in therapy but the records do not indicate that her deficits require the 
additional unique skills of a professional therapist to safely and effectively provide treatment. Services do not 
need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The 
enrollee has been trained in a home exercise program. The requested services are not part of a maintenance 
program and 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 8 additional home health PT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional home health physical therapy (PT) visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve these services. You say that you need help cleaning your apartment. The 
Plan denied your request. The Plan says you are not eligible for the services because you are not homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network optometrist. 
 
You asked the Plan to pre-approve these services. You say that you would like to see this provider. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network optometrist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for the enrollee on tooth #7. 
 
You asked the Plan to pre-approve the services. You say that the enrollee presents with existing MIDFL 
composite restoration on tooth #7. The Plan denied your request. The Plan says the enrollee has exhausted the 
crown 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. The Plan covers crowns twice 
per year. 
 
The file shows that on August 11, 2020, crowns were approved for teeth #8 and #9. This is the maximum 
benefit for crowns in a calendar year. Based on this information, we decided that the Plan's rules for coverage 
of an additional crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
crown for the enrollee on tooth #7.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to home medical provider visits with an out-
of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to home medical provider visits with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consumer directed personal assistance services. 
 
You asked the Plan to pre-approve consumer directed personal assistance services. You say that the services 
are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of consumer directed personal assistance services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve consumer directed personal assistance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the three remaining additional acupuncture visits. 
 
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 there is a $0 copayment per visit for up 24 acupuncture visits per year. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the three still denied acupuncture visits have not been met. Specifically, once the plan's five approved visits are 
used, you will have used your allotment of 24 visits for the year. Therefore, we decided that the Plan does not 
have to pre-approve the three remaining additional acupuncture visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily skilled services are no longer required, and the continuation of SNF 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 the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine additional home health occupational therapy visits. 
 
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 eight visits have been approved, which is sufficient. 
 
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 records do not show that skilled therapy services are required to 
effectively provide treatment, care, and/or services in order to improve your level of function, or to 
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The 
documentation reveals that you have had prior OT and the documentation does not reveal current ongoing 
functional deficits that requires ongoing skilled therapy. 
 
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 nine additional home health occupational therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you were told that this would be covered by 
Medicare. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, 
because you do not meet the Medicare guidelines for this testing. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA1 and BRCA2 genetic testing are covered 
when certain clinical criteria have been 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 genetic testing. Our reviewer says that 
you do not meet the Medicare criteria for BRCA1 and BRCA2 testing. Our physician reviewer found you are 
noted to have breast cancer, which was first diagnosed in your 60s. There is no evidence of family history of 
early age cancers. The requested test is not necessary to diagnose or treat you. Therefore, the requested testing 
is not medically reasonable and 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA1 and BRCA2 genetic testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your 
request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be approved. 
 
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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found the record does not show a failed trial of the 
plan preferred drugs or any reason why they would be unsafe or ineffective 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 Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty wheeled walker. 
 
You asked the Plan to pre-approve a heavy duty wheeled walker (E0149). You say that your current walker is 
too small and hurts your hips. The Plan denied your request. The Plan says you do not weigh more than 300 
pounds. 
 
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. Weight criteria for the requested walker is not met. Based on this 
information, we decided that Medicare rules for coverage of a heavy duty wheeled walker (E0149) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty wheeled walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk and it is difficult for you to stand 
for long periods of time. The Plan denied your request. The Plan says the denial of authorization for IRF 
service is correct. 
 
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. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require, or be able to perform, 15 hours per week of rehabilitative services with regular physician 
oversight. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6068, D7250, and D7953). 
 
You asked the Plan to pre-approve the services. You say that your tooth broke off and was jagged in your 
mouth. The Plan denied your request. The Plan says these services are not covered under your benefit package. 
 
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 
dental services (D6068, D7250, and D7953).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on December 12, 2019. 
 
You asked the Plan to pay for the lab services. You say that these services were referred by the patient's 
physician.  You say that you rely on the referring physician to obtain prior authorization. The Plan denied your 
request. The Plan says that unauthorized, non-plan care is not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab services by a plan provider. As a plan provider, the referring provider is 
supposed to know when authorization is needed and is supposed to follow plan rules. The file does not show 
that the plan provided notice that the lab services would not be covered because they were ordered by a plan 
provider. Under Medicare rules, this means the lab services is considered approved by the plan. Therefore, we 
decided that the Plan has to pay for lab services provided on December 12, 2019.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for removals of cataract with insertion of lens 
(66984) performed on January 15 and January 29, 2020. 
 
You asked the Plan to waive the copayment for removals of cataract with insertion of lens. You say that you 
were quoted a lower price prior to the service. The Plan denied your request. The Plan says the correct 
copayment was 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 $395 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center.  
 
You have been asked to pay a $395 copayment for removals of cataract with insertion of lens. A removal of 
cataract with insertion of lens falls within the "Outpatient Surgery and Other Medical Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 removals of cataract with insertion of lens (66984) performed on January 15 and 
January 29, 2020.  
 
Your complaint about being provided with erroneous or misleading pricing information is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 12, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says the enrollee 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 the medical services provided on February 12, 2020 by an out of 
network (OON) provider.