Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that this provider is closer to home. The Plan denied 
your request. The Plan says there are in-network options for physical therapy services. 
 
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 services at issue in this appeal. We were able to confirm that the Plan has 
contract providers located within reasonable distance and travel time from your home who can provide the 
requested services. We found no exception that would require the Plan to pre-approve these OON services. 
Therefore, we decided that the Plan does not have to pre-approve physical therapy 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 continued admission to an inpatient behavioral health 
facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says treatment can happen in a lower level of care, such as outpatient. 
 
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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not 
meet the criteria for continued admission going forward, as you were not shown to be a danger to yourself or 
others. You were not showing any auditory or visual hallucinations. You were cooperative and compliant with 
treatment. You were not showing any threats to safety. The health plan's denial of continued inpatient 
psychiatric services is appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to an inpatient behavioral health facility.
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 a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) 
following a motor vehicle collision. The enrollee was intubated/ventilated for respiratory issues and surgeries, 
eventually receiving a tracheotomy. The enrollee is not on a ventilator. There is no evidence that the enrollee 
requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level 
of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current 
ACH until such time 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyelid sheets (A9270).
You asked the Plan to pre-approve the eyelid sheets. You say that the sheets are medically necessary to treat dry eyes. The Plan denied your request. The Plan says the eyelid sheets are not considered medical equipment and are not eligible for coverage.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve eyelid sheets (A9270).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira kit. 
 
You asked the Plan to pre-approve Humira. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira kit.  
 
Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there are in-network providers available to 
supply this equipment. 
 
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 
a home ventilator (E0466) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that due to the enrollee's medical 
conditions he needs a fully electric hospital bed The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed (E0265).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Ellipta. 
 
You asked the Plan to pre-approve Trelegy Ellipta. You say that you would like reconsideration because this 
drug is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Ellipta.  
 
Benefits for Trelegy Ellipta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (A4520). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the adult diapers are medically 
necessary due to urinary incontinence. The Plan denied your request. The Plan says these are not covered items 
as they are not reusable. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4520).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network pain management services.
You asked the Plan to pre-approve out-of-network pain management services. You say that you are in a lot of pain and need epidural shots. You say that you want to continue seeing your provider. The Plan denied your request. The Plan says services can be provided at an in-network, community level setting.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve out-of-network pain management services. Our reviewer says that the request to go out of network is not medically reasonable or necessary. Our physician reviewer found there are no complex or unusual medical conditions that requires the use of a tertiary care facility and the in-network specialist can perform the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of out-of-network pain management services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-network pain management services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Acetaminophen, Apixaban, Atorvastatin, Diltiazem, Gabapentin, Senna-Docusate, Codeine, Hydrochlorothiazide, and Levothyroxine.

You asked the Plan to pay for the self-administered drugs. You say that you would like the self-administered drugs to be covered. The Plan denied your request. The Plan says these drugs are self-administered drugs, and are not covered by Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Acetaminophen, Apixaban, Atorvastatin, Diltiazem, Gabapentin, Senna-Docusate, Codeine, Hydrochlorothiazide, and Levothyroxine.

Benefits for the Acetaminophen, Apixaban, Atorvastatin, Diltiazem, Gabapentin, Senna-Docusate, Codeine, Hydrochlorothiazide, and Levothyroxine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 19, 2021 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. 
The Plan says that the referring provider is out-of-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on January 19, 2021 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS HF System (CPT code 33289, and
C2624), for the enrollee.

You asked the Plan to pre-approve the services. You say that the system will allow you to better monitor and
manage those symptoms that lead to repeat heart failure hospitalizations. The Plan denied your request. The
Plan says the services are considered experimental and investigational.

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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further
clinical study is needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS
device is medically reasonable and necessary for the enrollee 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. Therefore, we decided that the Plan does not
have to pre-approve CardioMEMS HF System (CPT code 33289, and C2624), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64633) provided on November 6, 2020.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 injections (64633) provided on November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on October 4, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you received a letter about cost share 
being waived. You say that you should be reimbursed. The Plan denied your request. The Plan says the 
copayment applied 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 $200 
copayment for all other diagnostic and nuclear medicine radiological services. 
 
You have been asked to pay $129.15, which is less than the standard $200 copayment for the CT scan. The CT 
scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The 
Plan says that only copayments for primary care visits and specialist visits are being waived. The records show 
the CT scan was billed by a facility. 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 the CT scan 
provided on October 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prosthetics and supplies.

You asked the Plan to waive the coinsurance for the prosthetics and supplies. You say that you were informed you did not owe anything, and the provider was paid in full. You say that you are disabled and have limited income. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for prosthetic devices and related supplies from an in-network prosthetics provider.

You have been asked to pay $1,306.61, which is 20% of the allowed amount for the prosthetics and supplies. The allowed amount is $6,533.08 (20% x $6,533.08 = $1,306.61). The prosthetics and supplies fall within the "Prosthetic devices and related supplies" 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 the prosthetics and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture with flexible base (D5226) and a 
partial upper denture with flexible base (D5225). 
 
You asked the Plan to pre-approve the dental items. You say that the provider already took impressions for the 
partial dentures. You say that the claim was denied. You say that when you called the dental plan you were 
given reference numbers for approvals. The Plan denied your request. The Plan says partial dentures with 
flexible bases are not listed as covered services. 
 
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. The Customer Handbook clearly states that if a dental item or service 
is not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to pre-
approve a partial lower denture with flexible base (D5226) and a partial upper denture with flexible base 
(D5225).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will benefit from rehabilitation. The Plan denied 
your request. The Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. Our physician reviewer also found that there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the 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 the acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you cannot be left alone. The Plan 
denied your request. The Plan says you do not need skilled services and are not homebound. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the criteria for coverage of home health care have not been met. Our physician reviewer found the 
medical records show that you do not require skilled nursing or rehabilitation services. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
Furthermore, the documentation does not support that you are homebound or that the requested services are 
medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.