Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation supports the 
need for LTACH care. The Plan denied your request. The Plan says the requirements for coverage of LTACH 
care have not been met. The Plan says that the services needed could be provided in another setting. 
 
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 short-term acute care hospital can provide for all the enrollees present inpatient 
care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the 
short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such 
as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on November 3, 2019. 
 
You asked the Plan to pay for the air ambulance services. You say that the air ambulance services provided 
were medically necessary. The Plan denied your request. The Plan says the air ambulance services provided 
were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the air ambulance services. Our reviewer 
says that the air ambulance services provided were not medically necessary. Our physician reviewer found the 
enrollee was diagnosed with systemic inflammatory response syndrome (SIRS) related to URI and was 
transported on 11/3/2019 via air ambulance. He required mechanical ventilation and pressors. Transportation 
was needed as the sending hospital did not have sufficient ICU physicians to monitor the enrollee overnight. 
Only one physician was available for overnight coverage. The appellant states there was not ground transport 
available at that immediate time and surrounding area that included personnel that could ride in the ambulance 
to support the enrollee's ventilator needs. 
 
The documentation does not support that the enrollee suffers from an illness or injury that contraindicates 
transportation by any means other than ambulance. The documentation did not provide sufficient evidence of 
the enrollee requiring urgent need for transport as he was successfully managed at the sending hospital's ICU 
and breathing machine with pressor support at the time for immediate needs until transportation services 
became available. The documentation does, however, support that the transferring hospital did not have 
adequate facilities to provide overnight services needed by the enrollee for a full length of treatment. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services provided on November 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (electrical connection, 
remote joystick, expandable controller, harness) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. 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. 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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input 
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc). The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee has adequate upper extremity function to operate the power 
options through their own individual 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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (electrical connection, remote joystick, expandable 
controller, harness) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensor for use with interstitial continuous glucose 
monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277). 
 
You asked the Plan to pre-approve the sensor and transmitter. You say that that these medical supplies are 
medically necessary. The Plan denied your request. The Plan says that these items are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the 
DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies 
used with a non-therapeutic CGM. 
 
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting 
supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and 
supplies. Therefore, we decided that the Plan does not have to pre-approve sensor for use with interstitial 
continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose 
monitoring (A9277).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on January 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the ear wax removal you had at a specialist's office on 
February 10, 2020 
 
You asked the Plan to waive the deductible for the ear wax removal. You say that you should not have a 
deductible for these specialist services. The Plan denied your request. The Plan says that it has waived the 
deductible for the office visit you had with the specialist, but the deductible applies to the ear wax removal you 
had. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  We looked at your contract with the Plan. We did not see where the 
contract says enrollees must pay a $1,000 annual deductible for ear wax removal services you receive from a 
specialist. In fact, your Evidence of Coverage states that the deductible does not apply to physician specialist 
services.  A reasonable interpretation of this contract provision would be that the ear wax removal services you 
received in your specialists office would fall into this category, making the deductible inapplicable. Therefore, 
we decided that the Plan has to waive the deductible for the ear wax removal you had at a specialist's office on 
February 10, 2020  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) scans (70491, 
71260, 74178, Q9967) and a contrast injection provided April 2, 2020. 
 
You asked the Plan to waive the copayment for the CT scans and contrast. You say that the copayment should 
only be $85. The Plan denied your request. The Plan says the correct cost-sharing 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 an $85 
copayment for Diagnostic Radiology and a 20% coinsurance for Part B drugs. 
 
You have been asked to pay three $85 copayments for Diagnostic Radiology and a 20% coinsurance for Part B 
drugs. The CT scans are considered diagnostic radiology and the Contrast injections are considered Part B 
drugs. 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 Computed Tomography (CT) scans (70491, 
71260, 74178, Q9967) and a contrast injection provided April 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve headrest (E0955). 
 
You asked the Plan to pre-approve the headrest. You say that you would like reconsideration because this 
supply is medically necessary. The Plan denied your request. The Plan says this accessory is included with the 
allowance for the wheelchair. 
 
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 headrest. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the headrest is included in the allowance of the K0841 wheelchair and approved components. 
 
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 headrest have not been met. Therefore, we decided that the Plan does not 
have to pre-approve headrest (E0955).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member has no skilled therapy or skilled nursing service needs. 
 
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 your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2303, V2750, V2020) provided March 17, 
2020. 
 
You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered. The Plan denied 
your request. The Plan says the benefit has been exhausted. 
 
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 up to $150 for eyewear. 
 
We looked at the file and the Plan's rules. The eyeglasses were $374. This exceeds the $150 allowance. 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 eyeglasses (V2303, V2750, V2020) provided 
March 17, 2020 beyond the $150 already paid.
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 there is no clear benefit of acute inpatient rehab over less intensive 
settings. 
 
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 to be able to perform fifteen hours per week of rehabilitative services or to require regular physician 
evaluation. 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says rules for coverage have not been met. 
 
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 does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. Services can be provided 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
to get to medical appointments. The Plan denied your request. The Plan says that you have used your allotted 
transportation 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 Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve radiation therapy. You say that in-network providers do not use the same 
technique that you use. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an 
in-network provider. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services (97161) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are 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 
the physical therapy services (97161) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee does not need to see a doctor every day 
and had a stable physical exam. The Plan says that the enrollee does not need hospital level care and does not 
have specialized nursing needs. The Plan says that LTACH care 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 is currently undergoing treatment at an acute care hospital (ACH) for 
bacteremia, in the setting of valvular heart disease.  The enrollee is not intubated/ventilated.  There is no 
evidence that the enrollee requires services that are not currently available.  There is no advantage in 
transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such a time that no 
acute services are required.  The enrollee can then be transferred/discharged to a lower level of care for any 
ongoing long term care needs. 
 
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.