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

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 8, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopy services provided on November 4, 2019. 
 
You asked the Plan to pay for endoscopy services. You say that you are enrolled with Medicare. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because this provider is 
not enrolled with Medicare as an ambulatory surgical center. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive coverage of and payment for 
ambulatory surgical center (ASC) services, a facility must be certified as meeting the requirements for an ASC 
and enter into a written agreement with CMS.  
 
We looked at the file and Medicare rules. This provider is not certified as an ambulatory surgical center, 
therefore this claim submitted with an ambulatory surgical center bill type is not covered by Medicare. Based 
on this information, we decided that Medicare rules for coverage of endoscopy services have not been met. 
Therefore, we decided that the Plan does not have to pay for endoscopy services provided on November 4, 
2019.
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. The Plan denied your request. The Plan says LTACH 
admission is not medically reasonable and 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 that ongoing care needs include intravenous antibiotics, surveillance laboratory 
studies, wound care, and therapy services. The documentation does not support that the enrollee requires 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no required medical services identified that are available at the LTACH, that are not available at the 
current health care setting being offered by the health plan. Consequently, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox, 100 units, every 90 days for 365 days. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee has tried speech-language therapy and is 
unsure if it worked. You say that the enrollee has vocal strain but no pain when talking. You also say that the 
enrollee has occasional dysphagia symptoms and frequent throat clearing. The Plan denied your request. The 
Plan says the requested drug is not covered for the diagnosis that was submitted. The Plan also says that the 
requested drug is not medically necessary. 
 
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 Botox. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation that was provided does not 
show that the criteria for coverage has been met. The reviewer also found that the documentation does not 
support that the Botox is safe and effective for the enrollee. Therefore, the requested drug is not medically 
reasonable and 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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox, 100 units, every 90 days for 365 days.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that that there is no evidence provided that 
the member's treatment needs could not be met at a less restrictive, outpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are medically reasonable and necessary for the 
enrollee in this case. Based upon review the records provided this patient does meet the criteria for acute 
inpatient mental health treatment as although this patient was not shown to be a danger to himself or others but 
was without agitation or aggression without perceptual disturbance including auditory, visual hallucinations or 
delusions, he was difficult to manage, irritable and agitated. Our physician reviewer found that the enrollee's 
condition meets Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve inpatient psychiatric hospital services for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve the endosteal implant. You say that there is no saving the tooth, and you 
need an implant to prevent your teeth from spreading. The Plan denied your request. The Plan says this service 
is not a covered benefit. 
 
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 pre-approve a 
surgical placement of implant body: endosteal implant (D6010).
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 are appealing based on medical 
necessity. The Plan denied your request. The Plan says the denial of authorization for LTACH service is 
correct. 
 
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 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 he is currently receiving care. Consequently, 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
24, 2017 to August 22, 2017. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the provided did not bill with an appropriate Q 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was not billed with the required Q code. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from June 24, 2017 to August 22, 2017.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 10, 2020.

You asked the Plan to pay for the ambulance services. You say that the medics gave you an EKG and this service is covered. 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 on January 10, 2020. 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 by Franklin County Emergency Service on January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on January 15, 2020 to January 17, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transferred to 
another facility. You say that you were an inpatient the whole time. The Plan denied your request. The Plan 
says the correct copayment 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 $393 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $393 copayment per day for days 1-2 for an inpatient hospital stay. The total 
amount you are being asked to pay is $786 ($393 x 2 days = $786). The correct copayment has been applied to 
the inpatient hospital stay provided by a participating facility. A copayment is applied per each hospital 
inpatient services are provided at. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided by a 
participating provider on January 15, 2020 to January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics and orthopedic shoes. 
 
You asked the Plan to pay for foot orthotics and orthopedic shoes. You say that you hurt your angle and your 
doctor recommended foot orthotics and shoes designed to help your condition. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records do not show that these shoes and orthotics were provided due to diabetic foot disease and you do not 
wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides 
coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics and orthopedic shoes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that the provider suggested 
this for your gums to stay healthy. You say that this should be covered since the dentist suggested it. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 pre-approve 
periodontal scaling and root planing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and 
D5120). 
 
You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). You say that 
your boat sank which had your dentures on it. You say that you still have the pins in your mouth for the 
dentures which are causing severe pain. The Plan denied your request. The Plan says the service exceeds the 
maximum count allowed per period. 
 
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 
one complete upper and lower denture every five plan years. The Plan paid for a complete upper and lower 
denture provided on October 25, 2018, which exhausted your benefit. Therefore, we decided that the Plan does 
not have to pre-approve the complete upper and lower denture (D5110 and D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete lower denture (D5120). 
 
You asked the Plan to pre-approve the complete lower denture (D5120). You say that the teeth started to fall 
out of the bottom denture, you developed an abscess and required gum surgery. You say that because of the 
gum surgery the denture no longer fits. The Plan denied your request. The Plan says the service requested is 
only covered one time in a 60-month time period (5 years). 
 
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 
one complete or immediate denture every 60 months. The Plan paid for a complete lower denture on March 13, 
2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH level of care is necessary. 
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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not already being 
provided at the current setting. There are no services at the LTACH that the enrollee requires that are not 
available and covered at the current setting. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Continuing care at the current hospital appears appropriate at the time. 
Transfer to a lower level of care may be considered when the enrollee is more stable and fully treated. 
 
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 the LTACH services.
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 the documentation provided supports the need for 
IRF care. You say that the enrollee has been making progress and will greatly benefit from more intense 
therapy. The Plan denied your request. The Plan says the clinical information received does not show that the 
guidelines for IRF care have been met. The Plan say that the enrollee's needs can be safely met in a less 
intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an 
IRF. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a 
participating provider on June 16, 2020. 
 
You asked the Plan to waive the copayment for diagnostic radiology services. You say that you were never told 
that there would be a copay for this. The Plan denied your request. The Plan says the correct copayment 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 $200 
copayment for outpatient diagnostic tests/diagnostic radiology services.  
 
You have been asked to pay a $200 copayment for diagnostic radiology services. Diagnostic radiology services 
fall within the outpatient diagnostic tests/diagnostic 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 diagnostic radiology services provided by a participating provider on 
June 16, 2020.