Persius/hicric huggingface dataset:
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 SNF admission. You say that the enrollee's daughter feels that the enrollee 
needs sub-acute rehabilitation. The Plan denied your request. The Plan says the denial of authorization for SNF 
care is correct. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a Skilled Nursing Facility (SNF) 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on September 
2, 2018. 
 
You asked the Plan to pay for this claim. You say that this claim was filed within the Medicare time limit. The 
Plan denied your request. The Plan says the regulations state the final claim must be submitted within 120 days 
of the start date of the episode or 60 days after the paid date of the RAP, whichever is greater, or the RAP 
payment will be cancelled. The Plan states the provider admits they submitted the complete claim on October 
24, 2019 which is 418 days after the start date and 385 days after the paid date. 
 
The Plan must follow Medicare rules. Medicare rules say that RAP claims have specific timeframes in which 
they must be submitted. In this case, the claim submission was untimely.  Therefore, we decided that the Plan 
does not have to pay for home health services provided to the enrollee on September 2, 2018.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on September 
17, 2019 and billed under code 99350. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says these services were provided by a licensed vocation nurse or registered nurse. Code 
99350 only applies to physician services provided in the home.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the claim submitted cannot be paid 
as billed based on the type of practitioner who performed the services. Medicare rules for coverage of this 
service have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
provided to the enrollee on September 17, 2019 and billed under code 99350.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF services after October 28, 2020. 
 
You asked the Plan to pre-approve continuation of SNF services. You say that your physician has recommend 
two weeks of physical therapy in the SNF. The Plan denied your request. The Plan says Medicare criteria for 
continued SNF level of coverage were not met. There is no daily skilled nurse or therapist 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 continuation of SNF services. Our 
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a 
nursing perspective, you received oral medications. This included Coumadin, which was dose adjusted based 
upon your PT/INR. You had stable vital signs. You were treated for pain with effect. 
Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the 
SNF.  By the dates in question, you were at a set up level with functional mobility including gait to 150 
feet. You required varying assist with activities of daily living. There are no identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy 
services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF services after October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an intensive 
rehabilitation program 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 does not require the intensity of services provided at an IRF. Our 
reviewer found that specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation services 
received on June 1 to June 5, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital observation services. You say that the 
hospital should take responsibility and you should be compensated for the irresponsible way you were treated. 
The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient hospital observation services.  
 
You have been asked to pay a $275 copayment for outpatient hospital observation services. Outpatient hospital 
observation services falls within the "Outpatient Hospital Observation" 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 outpatient hospital observation services received on June 1 to June 5, 
2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided to the enrollee on May 18, 2020 that were 
not related to manual manipulation of the spine. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says services not related to manual manipulation of the spine are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for services 
provided to the enrollee on May 18, 2020 that were not related to manual manipulation of the spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
non-participating provider on June 18, 2020. 
 
You asked the Plan to waive the coinsurance for a knee brace. You say that the brace didn't fit correctly. You 
say that you were not given a choice on whether you wanted it or not. The Plan denied your request. The Plan 
says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a knee brace. The total allowed 
amount is $766.93. The total amount you are being asked to pay is $153.39 ($766.93 x 20% = $153.39). Since 
durable medical equipment was provided, the correct coinsurance has been applied. A knee brace falls within 
the durable medical equipment 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 coinsurance for 
durable medical equipment provided by a non-participating provider on June 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that 
Orthovisc is not medically reasonable and necessary in this case. There are no current medical records 
presented to support the medical necessity of this request. There is no documentation by the physician 
discussing failure of conservative treatment, or radiographic evidence to support the diagnosis of osteoarthritis. 
There is no documentation of significant improvement in knee pain and known improvement in functional 
capacity resulting from the previous series of injections, or the dates of prior injections. Our physician reviewer 
found that your condition does not meet Medicare criteria for coverage of Orthovisc. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic radiology services provided by 
a participating provider on June 22, 2020, to June 23, 2020. 
 
You asked the Plan to waive the copayment for therapeutic radiology services. You say that you already met 
your maximum out-of-pocket amount. The Plan denied your request. The Plan says some claims have been 
reprocessed, leaving the correct amount still owed. 
 
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 $25 
copayment for outpatient diagnostic tests/therapeutic radiology services.  
 
You have been asked to pay a $25 copayment for therapeutic radiology services. The total amount you are 
being asked to pay is $36.90 ($25 + $11.90 = $36.90). The correct copayment has been applied to these 
services. Therapeutic radiology services fall within the outpatient diagnostic tests/therapeutic radiology 
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 copayment for therapeutic radiology 
services provided by a participating provider on June 22, 2020, to June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hemodialysis services (90935) received 
from June 1 to June 29, 2020. 
 
You asked the Plan to waive the coinsurance for hemodialysis services. You say that you've already reached 
your maximum out-of-pocket for the year. The Plan denied your request. The Plan says the correct coinsurance 
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 20% 
coinsurance for Medicare-covered dialysis services within the service area when ordered by your primary care 
provider. The Plan contract also says that there is a limit to how much you have to pay out-of-pocket each year 
for in-network medical services that are covered under Medicare Part A and Part B. In 2020 the maximum out-
of-pocket is $3,400. 
 
You have been asked to pay $780.24, or less than 20% of the Plan-allowed amount of $3,931.20, for 
hemodialysis services. Hemodialysis services fall within the "Services to treat kidney disease" benefit category. 
The case record documents that you reached your maximum out-of-pocket for the 2020 benefit year after June 
29, 2020. This means that you have been asked to pay less than or equal to 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 coinsurance for hemodialysis services 
(90935) received from June 1 to June 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says Aranesp is subject to 
step therapy. The Plan also says that step therapy encourages you to try the Plan's equally effective preferred 
drug, Retacrit. 
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee 
has not tried or had an inadequate response to Retacrit (Epoetin Alfa) therapy for at least two consecutive 
months with appropriate dose adjustment. Our reviewer also found that Retacrit is not likely to be less effective 
and/or likely have adverse effects for the enrollee. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services.The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on June 8, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says services not directly related to manual manipulation are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided to the enrollee on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport you received on July 
9, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you shouldn't have to 
pay for this ambulance ride because you didn't authorize it. The Plan denied your request. The Plan says you 
were charged this copayment correctly. 
 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for the ambulance transport. This copayment applies regardless 
of the reason for the transport. 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 ambulance transport you 
received on July 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan 
(71250) provided. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 
copayment for advanced imaging services.  
 
You have been asked to pay a $112.91 copayment for the CT scan. The Medicare allowed amount of $112.91 
is less than the $180 copayment noted in the Evidence of Coverage. The CT scan falls within the advanced 
imaging 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 copayment for a Computed 
Tomography (CT) scan (71250) provided.
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level does not require 
skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely 
and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does 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, this enrollee does not require the necessary services only 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 admission to a SNF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 28, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 February 28, 2020.