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

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve the OON care. You say that you already had a biopsy with the OON 
provider, who marked the area that requires surgery. You say that you need to go back in and get the 
surrounding tissue. You say that you have been diagnosed with cancer and that your other breast was 
previously removed by the OON provider. You say that you have confidence in the OON provider and would 
like him to perform the needed surgery. The Plan denied your request. The Plan says there are participating 
providers and facilities that can provide the requested procedure services. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 OON care. Our reviewer says that 
the criteria for OON care have not been met. Our physician reviewer found there is nothing unique about your 
condition that would make it medically necessary for you to continue care with the OON provider. 
 
The Plan has shown that they have in-network specialists who have the qualifications and expertise necessary 
to meet the current medical Standards of Care required for treatment of your condition. Our physician reviewer 
found that your medical management and follow-up care can be safely transitioned to an in-network specialist 
at this time. 
 
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 OON care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuation of care with an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary 
bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for 
an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary 
bed. The head of the bed does not need to be elevated more than thirty degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. The request for a semi-
electric hospital bed is not medically necessary for this 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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for catheter placement and emergency care 
provided from August 6, 2019, to August 10, 2019. 
 
You asked the Plan to waive the copayments for catheter placement and emergency care. You say that the 
procedures are due to false positive test results and you disagree with the charges. 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 $325 
copayment for outpatient hospital services and a $90 copayment for emergency care. 
 
You received catheter placement on August 6, 2019. Therefore, you responsible to pay the $325 copayment.  
 
You received emergency care from August 9, 2019, to August 10, 2019. Therefore, you are responsible to pay 
the $90 copayment.  
 
The total amount you owe is: $415.   
 
You have been asked to pay the total copayment amount of $415 for catheter placement and emergency care. 
Catheter placement and emergency care fall within the outpatient hospital 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 copayments for catheter placement and emergency care provided from 
August 6, 2019, to August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you provide these services in good faith that the 
facility would obtain all prior authorizations that would be needed. The Plan denied your request. The Plan says 
prior authorization was not obtained. 
 
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 had network providers 
available who could have provided 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 July 29, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on September 16, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that you got the eyeglasses after cataract surgery so they 
should be covered. The Plan denied your request. The Plan says the provider did not use the correct diagnosis 
code on the claim. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services after cataract surgery. 
 
We looked at the file and the Plan's rules. The diagnosis on the claim is not for cataract surgery. The provider 
must submit a corrected claim. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses 
purchased on September 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab. 
 
You asked the Plan to pre-approve Nivolumab. You say that this is medically necessary. The Plan denied your 
request. The Plan says this use is not supported. 
 
The Plan follows Medicare rules. Medicare rules say that chemotherapy agents may be covered if reasonable 
and medical necessity is met, the drug is FDA approved, and the drug is listed in the NCCN Clinical Practice 
Guidelines in Oncology (NCCN) with the specific ICD-10 diagnosis (that is being treated) for the drug/agent. 
 
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 Nivolumab. Our reviewer says that the 
requested use of Nivolumab is not supported. Our physician reviewer found the use of first line Nivolumab in 
small cell lung cancer is not supported by any literature or compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivolumab.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 14, 2020 by a non-
network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 May 14, 2020 
by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the temporary partial denture, extraction, bone graft, biologic 
materials and unspecified adjunctive procedure provided from March 21, 2020, through March 27, 2020. 
 
You asked the Plan to pay for the temporary partial denture, extraction, bone graft, biologic materials and 
unspecified adjunctive procedure. You say that this was not routine dental work. You say that you are 
requesting reimbursement under your medical coverage not dental. The Plan denied your request. The Plan 
says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
$400 for dental services every year. The Plan paid $400 toward your dental services, which exhausted your 
benefit. Since these services meet the definition of dental, they cannot be covered as medical. Therefore, we 
decided that the Plan does not have to pay for the temporary partial denture, extraction, bone graft, biologic 
materials and unspecified adjunctive procedure provided from March 21, 2020, through March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 28, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on September 28, 2020.
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 was admitted for an infection of the scrotum and groin. Medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. The documentation does not support that the enrollee requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that 
the enrollee requires 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) services. 
 
You asked the Plan to pre-approve the PET scan. You say that the examination is consistent with possible 
critical basal syndrome. You say that the requested PET scan is medically necessary. The Plan denied your 
request. The Plan says the requested PET scan is non-covered because there is no clinical documentation of a 
concern for Alzheimer's dementia or frontotemporal dementia. 
 
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 PET scan. Our reviewer says that 
the requested PET scan is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has been evaluated by neurology for imbalance with falls and stated mild cognitive 
impairment. The enrollee has had involuntary movements of her left hand. The examination is consistent with 
possible cortical basal syndrome with apraxia of the left hemibody. Magnetic resonance imaging was done on 
July 24, 2020, which demonstrated stable mild chronic microvascular white matter ischemic changes. 
Vestibular testing was reported to be negative. A transcranial doppler study demonstrated no focal stenosis of 
flow. An EEG was normal. A vestibular electro-nystagmography study was normal. The examination was 
noted to be consistent with possible corticobasal degeneration with apraxia of the left hemibody. The benefit of 
a PET scan in the evaluation of corticobasal degeneration with apraxia of the left hemibody has not been 
established. Currently, the treatment of corticobasal degeneration remains symptomatic. Testing which has no 
proven impact on the management of a medical diagnosis of a disease for the health of an enrollee is not a 
covered Medicare benefit. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) services.
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 need LTACH care. The Plan denied 
your request. The Plan says rules for LTACH care have not been 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 there is no documentation provided necessitating admission to an LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. 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. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left knee arthroscopy. 
 
You asked the Plan to pre-approve the knee surgery. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 knee surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee underwent radiographic evaluation that revealed mild to moderate joint space 
reduction in the medial compartment. There was no imaging of any articular cartilage defect. The reported 
mechanical issues were not sufficiently characterized in detail to support the requested procedure. In addition, 
the absence of any imaging demonstrating meniscal tear further supports that the requested knee surgery is not 
medically reasonable or 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 knee surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve left knee arthroscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy with a licensed marriage and family 
therapist. 
 
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says licensed marriage and family therapist is not eligible to bill 
Medicare per Medicare rules. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Licensed marriage and family 
therapist is not eligible to bill Medicare per Medicare rules. The rules say that other providers of mental health 
services licensed or otherwise authorized by the state in which they practice (e.g., licensed clinical professional 
counselors, licensed marriage and family therapists). These other providers may not bill Medicare directly for 
their services. Therefore, we decided that the Plan does not have to pre-approve psychotherapy with a licensed 
marriage and family therapist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve noninvasive interface ventilator to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the enrollee has used this provider's services since 
2018 and wishes to stay with this provider due to the quality of care they provide to their patients. The Plan 
denied your request. The Plan says this provider is out-of-network. The Plan states the service requested, 
noninvasive interface ventilator, is available in-network 
 
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 
noninvasive interface ventilator to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on November 8, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that the Plan should pay the balance of this 
claim. The Plan denied your request. The Plan says the primary insurance carrier has paid you above the 
Medicare allowable for this service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer.  
 
The record shows the primary insurer has paid above the Medicare allowable for this service. Combined the 
payment should not exceed the normal allowable amount. Therefore, we decided that the Plan does not have to 
pay for the ambulance service provided on November 8, 2019.