Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need to get to your doctor's 
appointments. The Plan denied your request. The Plan says the 51st trip and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
 
 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the insulin regimen is not adjusted based on the results of the blood glucose testing. 
 
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 system. Our reviewer says that the 
requested system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to have type II diabetes, for which you take oral medication and fixed doses of insulin.  
While it is reported that you check her blood glucose six times a day, there is no evidence of this (log), nor is 
there evidence that you use the results of such frequent testing to actually adjust the dosage of your insulin 
multiple times per day. Therefore, the requested CGM is 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitoring system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased May 9, 2020 from an out of 
network provider. 
 
You asked the Plan to pay for the hearing aids. You say that attached are itemized cost and services and proof 
of credit card payment and you are requesting reimbursement. The Plan denied your request. The Plan says 
enrollees must receive their hearing services in network through the plans participating vendor. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased in network through the plans participating vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids purchased May 9, 2020 from an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy 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 Prolia. Our reviewer says that the step 
therapy requirements have not been met for coverage of the requested drug. Our physician reviewer found that 
the documentation does not support a history of an osteoporotic fracture or previous treatment, 
contraindication, or intolerance to zoledronic acid. Step therapy, as outlined by the plan, requires this 
documentation. Without the support of the documentation, Prolia is not approved as step criteria 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the heart for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request is not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has a reported 
intermediate risk for cardiovascular disease and has been intolerant of statins in the past. She would likely meet 
criteria for lipid lowering therapy if her calcium score were elevated. If score was relatively low, she could 
avoid statin therapy based on AHA/ACC prevention guidelines. CT coronary calcium scanning is reasonable 
and medically necessary based on published guidelines when the ASCVD risk is borderline or intermediate 
along with shared decision making regarding starting statin therapy to lower LDL cholesterol and decrease the 
risk of CV disease. Therefore in this instance CT calcium scanning is reasonable and 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the heart for the enrollee.  
 
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: 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 believe that IRF care is necessary for you. The 
Plan denied your request. The Plan says the physician has recommended home health care which would meet 
your needs. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for pneumonia associated with a COVID 19 infection. Medical problems are stable. There are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The medical record supports a need for physical and occupational therapy, but it does not support a need 
for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says while you 
are a member of our plan you must use network providers to get your medical care and services. The only 
exceptions are emergencies, urgently needed services when the Plan?s network is not available (generally, 
when you are out of the area), out of area dialysis services, and cases in which the Plan authorizes the use of 
out of 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided  that the  Plandoes not haveto pre-approveadditional  routine  transportation  trips.You asked the  Planto pre-approvethe additional  trips.  You say  that you  need these  trips  to get to physical therapy  appointments.The  Plandenied  your  request. The  Plansaysthe 51st trip  and beyond  is  not  a covered benefit.Medicare  does not cover  transport  in  a vehicle  that  is  not  an ambulance.  However,  the Plan  offers  a transportation  benefit  that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan  covers  a maximum  of 50 one-way  trips  per year. We looked  at your  request,  the records  in  the  case file,  and  the rules.  Based on this  information,  we decided that  additional  trips  beyond  50 per year  cannot  be covered.Therefore,  we decided  that the Plandoes not haveto pre-approveadditional  routine  transportation  trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 6, 2019. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges 
because it was necessary to have you prescriptions refilled. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 $20 
copayment for primary care provider visits.  
 
You have been asked to pay a $20 copayment for an office visit. An office visit falls within the 
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 an office visit provided on August 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNFservices after October 15, 2020.You asked the Plan to pre-approve the continuation of SNF services after October 15, 2020. You say that you need additional SNF services because you still need help doing the activities of daily living.The Plan denied your request. The Plan says you do not require daily skilled therapy services and/or daily skilled nursing services.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 continuation of SNF services after October 15, 2020. Our reviewer says that daily skilled services are notmedicallynecessary. Our physician reviewer found that you do not require skilled nursing services withthe specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. You do not have complex wound care or other ongoing SNF level skilled nursing needs. Your functional leveldoes not requireskilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. You are not fully participating in therapy and refusing sessions. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis in a skilled nursing facility setting beyond the last covered date.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 continuation of SNF services after October 15, 2020 have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services after October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an attendant 
control (E2331) and a drive wheelchair cover with adhesive (K0108). 
 
You asked the Plan to pre-approve the items represented by codes E2300, E2331, and K0108. You say that the 
tilt and recline options were approved previously and you do not understand why it cannot be covered not. You 
say that the features which remain in dispute are medically necessary. The Plan denied your request. The Plan 
says the seat elevation, attendant drive control, and the drive wheel cover are not covered benefits under 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that power seat elevation feature is non-covered because it is not primary 
medical in nature and that if an attendant control is provided in addition to a beneficiary-operated drive control 
system, it will be denied as non-covered. 
 
 
 
The drive wheel cover with adhesive does not primarily serve a medical purpose. The power seat elevation 
feature requested is not primarily medical in nature. The attendant control being requested would be used in 
addition to a beneficiary-operated drive control system. Therefore, we decided that the Plan does not have to 
pre-approve a power seat elevation system (E2300), an attendant control (E2331) and a drive wheelchair cover 
with adhesive (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 February 10, 
2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 Durolane. Our reviewer says that the 
step therapy requirements are not met for coverage of the requested drug. Our physician reviewer found that 
the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as 
outlined by the plan, requires that one of these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. Without the support of the documentation, 
Durolane is not approved as step criteria have not been 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) visit (99285) and radiologic 
examination (X-ray) of chest (71045) provided on June 1, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ER visit and X-ray. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the provider is not recognized by Centers for Medicare and Medicaid 
and the member signed an ABN stating they understood and wanted to receive treatment anyway. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency room visit and X-ray have not been met. Specifically, the provider in this case is a 
freestanding emergency room that is not affiliated with a hospital. This means that the services are not covered 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the emergency room visit 
and X-ray provided on June 1, 2020
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (72050, 72072, 72110, 73110) provided 
on February 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON imaging services. You say that you were provided with incorrect insurance 
information. The Plan denied your request. The Plan says these 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 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 imaging services (72050, 72072, 72110, 
73110) provided on February 17, 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. 
 
You asked the Plan to pre-approve IRF care. 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 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 the enrollee required modified independence with activities of daily living and 
mobility. The enrollee does not have any parental medications, complex wound care or care needed for a 
feeding tube. The documentation does not support that the enrollee requires treatment by multiple therapies, 
including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The 
enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this informat ion, 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.