Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the over the counter drug purchased on May 9, 
2020. 
 
You asked the Plan to reimburse you for the over the counter drug. You say that the cashier swiped your card 
several times and it was declined. The Plan denied your request. The Plan says the purchase was approved at 
the time of the transaction. 
 
The Plan must follow Medicare rules. The transaction record shows the first transaction went through and left a 
zero balance. Therefore, we decided that the Plan does not have to reimburse you for the over the counter drug 
purchased on May 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond 
August 6, 2020. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the continued services are not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted 
to the SNF and had stable vital signs. You had uncomplicated left leg dressings. You received physical, 
occupational, and speech therapy in the SNF and need assistance with walking 150 feet with a rolling walker. 
You need varied assistance with activities of daily living. You have no skilled nursing or skilled therapy needs 
and do not require these services on a daily basis. As a practical matter, you do not require the necessary 
services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services beyond August 6, 2020.
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 disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital after being found unresponsive at home. She currently requires PEG tube feedings, mechanical 
ventilation weaning, respiratory therapy, and telemetry monitoring. The enrollee does not require services at 
the LTACH that are not already available at the current acute care hospital. Although she needs ongoing acute 
care services, the recent documented improvements suggest she is likely to be successfully weaned and stable 
for discharge to a lower level of care in less than 25 days, which would not warrant transfer to LTACH. The 
services available at the LTACH are already available and covered at the current facility and can be provided 
until the enrollee is able to be discharged to a lower level of care. Therefore, this request for LTACH services 
will be considered not medically necessary 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: 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 services are medically necessary. The 
Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital with acute mental status changes and hematuria. The hospitalization was complicated by acute 
respiratory failure requiring oxygen and use of norepinephrine, which has since stopped. Current needs include 
supplemental oxygen, Dobbhoff tube feeds, and intermittent hemodialysis. The enrollee does not requires 
services at the LTACH that are not already available at the current acute care hospital. There are no services 
available at the current LTACH that the enrollee requires that are not already covered and available at the 
current facility. The LTACH services are not reasonable or 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 3, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this testing should be coded with CPT 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood pressure monitor (blood pressure cuff). 
 
You asked the Plan to pre-approve blood pressure cuff. You say that due to COVID-19 you cannot get your 
blood pressure checked at the pharmacy and it is too far for you to drive to your doctor's office to get your 
blood pressure checked. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor (blood 
pressure cuff).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that you have medical issues that cause you 
to have difficulty getting off chairs, getting dressed, and doing other activities. The Plan denied your request. 
The Plan says you do not need skilled nursing or therapy services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered. 
 
We looked at the file and Medicare rules. No medical records were submitted to demonstrate that you have any 
skilled nursing or therapy needs. The requested personal care services are custodial in nature. Based on this 
information, we decided that Medicare rules for coverage of personal care services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve personal care services (T1019).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services. You say that these services are needed to 
treat the enrollee's OCD. The Plan denied your request. The Plan says there are in-network providers available 
for these 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 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 
outpatient mental health services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary testing to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve pulmonary testing. You say that you would like to be able to see an out-of-
network provider. The Plan denied your request. The Plan says there are in-network providers still available for 
these 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 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 
pulmonary testing to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that a friend referred you to this physician 
for your hip. You say this physician came highly recommended and you prefer to be treated by him instead of a 
Plan provider. The Plan denied your request. The Plan says you must receive care from in-network providers 
with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if 
the care cannot be provided with an in-network provider, which requires prior authorization from the plan.  
 
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 found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 27, 2020 by an 
out of network (OON) provider. 
 
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 provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 has network providers 
available who can provide 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 the laboratory services provided on February 27, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or 
equal (L5981) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968). 
 
You asked the Plan to pre-approve the prostheses. You say that you would like to return to coaching which 
involves running up and down the sidelines on the field. The Plan denied your request. The Plan says the 
requested prosthesis exceeds your need. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the prostheses have not been met. The notes do not show why the 
requested advanced foot and ankle are needed. That is why the requested prosthesis is still denied. A request 
for a foot and ankle that meet your needs and Medicare guidelines can be reviewed if submitted. Therefore, we 
decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or equal 
(L5981) and addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature 
(L5968).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inflatable bathtub (device to assist with bathing), for the 
enrollee. 
 
You asked the Plan to pre-approve the inflatable bathtub. You say that the item is necessary. The Plan denied 
your request. The Plan says this item is not covered for any condition because it does not serve a medical 
purpose and it is used to help keep the enrollee clean. 
 
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 inflatable bathtub (device to assist with bathing), for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided the 
enrollee on February 26, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic 
profiling for NSCLC, and the appropriate DEX Z-Code identifier must be entered adjacent to the CPT code 
[81479] in the comment/narrative field. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided the enrollee on February 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ultrasounds provided on February 29, 
2020. 
 
You asked the Plan to waive the copayments for ultrasounds. You say that this is a big change in charges and 
you disagree with the copayments. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for each radiological diagnostic service. 
 
You received two ultrasounds on February 29, 2020. Therefore, you are responsible to pay a $110 copayment 
per each ultrasound. The total amount you owe is: $110 (copayment) x 2 (ultrasounds) = $220.   
 
You have been asked to pay the total copayment amount of $220 for ultrasounds. Ultrasounds fall within the 
outpatient diagnostic tests and therapeutic services and 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 copayments for ultrasounds provided on February 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services from February 5, 2020 through 
February 27, 2020 provided by an in-network provider. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on February 5, 2020 and discharged on February 13, 2020. 
You were asked to pay a $360 copayment per day from February 5, 2020 through February 9, 2020, days 1-5 of 
your inpatient stay. There were no copayment charges from February 10, 2020, day 6 of your inpatient hospital 
care until your day of discharge February 13, 2020. Per your contract there is a $360 copayment per day 
required for days 1-5 for in-network inpatient hospital care.  
 
Furthermore, you received emergency care from February 25, 2020 through February 27, 2020. You are asked 
to pay a $120 copayment for emergency care. 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 services 
from February 5, 2020 through February 27, 2020 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 18, 
2019. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that your physician was not available 
to see you and you were told that you would only owe a regular office visit copayment. You also state that you 
were seen by a nurse practitioner, not a physician. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for specialist visits.  
 
The record shows that you had a visit with a non-primary care physician on December 18, 2019. Therefore, you 
are responsible to pay the $30 copayment.  
 
You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on December 18, 2019.