Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary 
and reasonable treatment. The enrollee does require skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a qualified therapist is required to safely and effectively provide medically 
necessary and reasonable treatment. Daily skilled services are required. The enrollee does not require the 
services on an inpatient basis, in a skilled nursing facility setting. Continued care in the acute inpatient 
rehabilitation facility is appropriate until the enrollee is stable to discharge to home. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the items are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair is covered when specific 
criteria is 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the 
records do not provide documentation of any condition such that you are at high risk for skin breakdown or that 
you have spasticity or the need for self-catheterization requiring power tilt. Records indicate you are 
independent with dressing, toileting and feeding and thus appears to have upper extremity strength and 
coordination to operate the controls with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option and 
accessories.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services (01936) provided on June 9, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that there is no record of extraordinary 
circumstances that would necessitate monitored anesthesia care for this procedure. 
 
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. Specifically, the record indicates that the Plan received medical records which 
they used to make their decision. The plan has failed to forward clinical information to substantiate that this 
service was not medically necessary. Therefore, we decided that the Plan has to pay for anesthesia services 
(01936) provided on June 9, 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: 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 it is not expected that the enrollee would actively participate in an 
intensive rehabilitation program at this time. 
 
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 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. 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: 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 it is felt that the enrollee no longer needs 
the level of care of the current facility and would benefit from LTACH care as the LTACH facility is a 
pulmonary center of excellence and can provide a better chance for a full recovery. 
 The Plan denied your request. The Plan says there is no expectation that acute hospital care will be needed for 
another 25 days. There is no possible clinical advantage to LTACH services over continued care in the current 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital on 11/22/20 with sepsis, shock, 
and altered mental status. The enrollee was diagnosed with bilateral pneumonia and respiratory failure, 
requiring BiPAP. On 12/1/20, the enrollee was in no acute distress. Her chest X-ray was reported to be 
worsening. Ceftriaxone and vancomycin were being administered.   
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee still requires daily skilled 
services to maintain her condition. The Plan denied your request. The Plan says daily skilled care is not needed. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 72-year-old 
female who was admitted to acute care on 11/7/20 due to a left MCA stroke with atrial fibrillation and left 
sided retinal hemorrhage. She was transferred to IRF on 11/12/20. From a nursing perspective, the beneficiary 
received oral medications. The beneficiary had stable vital signs. Her lungs were clear. Regarding rehabilitation 
services, the beneficiary received PT, ST and OT in the acute hospital.   The beneficiary was at a maximal 
assist level with bed mobility and transfers.  The beneficiary required varying assist with ADLs. She had 
 
 
aphasia, dysphagia and apraxia. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, these do not require daily skilled therapy services. This beneficiary does not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite Test Strip. 
 
You asked the Plan to pre-approve the Freestyle Lite Test Strip. You say that the patient is not using insulin. 
The Plan denied your request. The Plan says Accu-Chek is the preferred brand of test strips in the member's 
Plan. 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 Freestyle Lite Test Strip have not been met. 
Accu-Chek is the preferred brand of test strips in the member's plan. The Accu-Chek strips and reader work 
like the member's current meter. If the member is synchronizing their current meter with an insulin pump or 
another electronic device or have another reason to keep using it, please submit supporting information 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite Test Strip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 
4, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like reimbursement for 
what would normally be given to a participating dentist. The Plan denied your request. The Plan says this 
service is not a covered benefit. The Plan also says that you did not contact the Plan or vendor prior to 
receiving this service to verify coverage. 
 
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 pay for the 
periodontal maintenance (D4910) provided on February 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from SNF placement. 
The Plan denied your request. The Plan says that the member is not able to benefit from skilled therapy. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tertiary ophthalmology care, by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. You say that you have been seeing this specialist for seven 
years and wish to continue. The Plan denied your request. The Plan says your plan requires you to receive care 
from providers who are part of your primary care physician's (PCP) specialty 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 provider at issue in this case is not a network provider with the Plan. 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 physician reviewer found the plan has retinal specialists 
available in its network. The documentation does not support that ophthalmology services with a tertiary care 
provider are medically reasonable and necessary for you in this case. 
 
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.  
 
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 the services. Therefore, we decided that the Plan does 
not have to pre-approve Tertiary ophthalmology care, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140), first intraoral periapical x-ray 
(D0220), bitewing x-ray (D0270), and problem focused limited oral evaluation (D0140) provided. 
 
You asked the Plan to pay for the extraction, first intraoral periapical x-ray, bitewing x-ray, and problem 
focused limited oral evaluation. You say that these services were done as efficiently as possible. The Plan 
denied your request. The Plan says these services are not covered by the Plan. 
 
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 pay for the 
extraction (D7140), first intraoral periapical x-ray (D0220), bitewing x-ray (D0270), and problem focused 
limited oral evaluation (D0140) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided. 
 
You asked the Plan to waive the copayments for specialist visits. You say that 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 $35 
copayment for specialist visits. 
 
You received three specialist visits. Therefore, you 
are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 (copayment) x 3 
(specialist visits) = $105.   
 
You have been asked to pay the total copayment amount of $105 for specialist visits. Specialist visits fall 
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 copayments for specialist visits provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) manual therapy sessions at an out-of-
network provider. 
 
You asked the Plan to pre-approve the services. You say that there are no therapists listed in the directory that 
practice at the Plan's preferred medical center, therefore, the physical therapy was recommended at an alternate 
location. The Plan denied your request. The Plan says they will not authorize medically necessary care outside 
the health plan network unless that care is not available within the 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 
twelve (12) manual therapy sessions at an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a non-participating dentist for a root canal. 
 
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 services from a non-participating provider are not covered. 
 
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 supplemental 
dental benefits from a participating provider.  
 
We looked at the file and the Plan?s rules. You are requesting services from a non-participating provider. Based 
on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a referral to a non-participating dentist for a 
root canal.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for laboratory services provided on June 1, 2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges 
because you thought copayments related to COVID-19 would be waived. The Plan denied your request. The 
Plan says that the claims were processed correctly and you are being charged the correct amount. 
 
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. The Plan did not provide medical records. Without medical records we cannot 
determine whether the antibody testing was done due to a medical condition or diagnosis. Therefore, we 
decided that the Plan has to waive the copayment for laboratory services provided on June 1, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on July 2, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that this service was considered preventative 
in the past and you feel the charges are way too high. 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 $450 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received an EGD on July 2, 2020, at an outpatient hospital facility. An EGD is considered a diagnostic 
procedure and is not considered preventative. Therefore, you are responsible to pay the $450 copayment.   
 
You have been asked to pay a $450 copayment for an EGD. An EGD falls within the outpatient surgery, 
including 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 an EGD provided on July 2, 2020.