Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (four skilled nursing and nine 
physical therapy visits) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing needs. The enrollee does not have documented skilled therapy 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services (four skilled nursing and nine physical therapy visits) for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronic acid injections. 
 
You asked the Plan to pre-approve the Hyaluronic acid. You say that you would like the injections approved to 
help with the pain that you are suffering from. The Plan denied your request. The Plan says your plan 
orthopedist has recommended new course of cortisone injections. 
 
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 the Hyaluronic acid. Our reviewer says 
that the Hyaluronic acid injections are not medically necessary. Our physician reviewer found the provider has 
recommended continuation of the corticosteroid injections or advised surgery. You are requesting the 
Hyaluronic acid injections. Our reviewer found that this course of treatment is a noted recommendation by the 
provider. Our physician reviewer also found that without the support of the documentation, medical necessity 
cannot be determined. 
 
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 Hyaluronic acid have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Hyaluronic acid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the provider has been practicing urology for 
over 50 years. The Plan denied your request. The Plan says there are urologists who are in-network that can 
provide the service. 
 
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 urology 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 urology services to be 
provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no need for ongoing therapy by a licensed occupational therapist. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found there is no need for 
ongoing care from a skilled therapist. This is not needed above non-skilled care and/or management via a home 
program supervised by trained, non-medical individuals (family). 
 
 
 
 
 
 
 
 
 
 
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 home health occupational therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute rehab 
facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be still requiring short-term acute care services, however, it 
does not appear that the enrollee will likely require at least an additional 25 days of acute care services. The 
enrollee does not require any services at the LTACH that are not already available in the current setting. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
setting. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
Transfer to a lower level of care may be considered soon. 
 
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 you were treated in the hospital for COVID positive pneumonia, respiratory failure, 
encephalopathy and a urinary tract infection. You are weak and deconditioned and is working with physical 
and occupational therapy. You are able to walk 30 feet with minimal assistance. You required moderate to 
maximum assistance for transfers and activities of daily living. The documentation does not support that you 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation does not support that you require an intensive rehabilitation therapy program. Your 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 inpatient rehabilitation facility (IRF) admission and 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, 
longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit 
and/or participate in an IRF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on June 3, 
2020. 
 
You asked the Plan to waive the copayment for lab tests. You say that you thought you would not have a 
copayment for your yearly physical. The Plan denied your request. The Plan says the copayment amount you 
are being charged is correct. 
 
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 $10 
copayment for lab tests.  
 
You have been asked to pay $10 copayment for lab tests. Lab tests 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 copayment 
for laboratory testing provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213), crowns (D2740) for teeth # 6, 9, 11, and 15, and core build up (D2950) for teeth # 6, 9, 11, 13, and 15.
You asked the Plan to pre-approve the core build up for teeth # 6, 9, 11, 13, and 15. You say that there is a significant amount of decay on teeth # 15 and 6. You also say that after the removal of the decay, over 70% of the tooth will be gone. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 an upper partial denture (D5213), crowns (D2740) for teeth # 6, 9, 11, and 15, and core build up (D2950) for teeth # 6, 9, 11, 13, and 15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, crown, and first intraoral periapical x-ray provided by an OON dentist on October 23, 2019 and October 29, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation, crown, and first intraoral periapical x-ray. You say that when you signed up for this coverage, the Plan representative did not inform you that your dentist was OON. The Plan denied your request. The Plan says these services were performed by an OON dentist. The Plan also says that non-emergency services provided by an OON provider are not available with your dental plan.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, crown, and first intraoral periapical x-ray provided by an OON dentist on October 23, 2019 and October 29, 2019.
Your complaint about being misled by the Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic testing provided on December 30, 2019. 
 
You asked the Plan to pay for the diagnostic testing. 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 diagnostic testing provided on December 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on March 31, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 home health services provided on March 31, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a tens unit (A4595) provided on March 18, 2020. 
 
You asked the Plan to pay for the tens unit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted did not include an 
itemized shipping or billing invoice to indicate the specific supplies or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a tens unit (A4595) provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the orthosis you received on December 24, 
2019 and the physical therapy visit you had on December 26, 2019. 
 
You asked the Plan to waive the cost sharing for the orthosis and physical therapy visit. You say that you were 
not aware that you would owe anything for these services beyond an office visit copay. The Plan denied your 
request. The Plan says they initially processed the claims for this orthosis and physical therapy visit as out-of-
network.  However, after confirming that the provider was in-network, the Plan has reprocessed your claims 
and is now charging you 20% coinsurance for the orthosis and a $30 copayment for the physical therapy visit. 
 
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 in-network durable medical equipment and a $30 copayment for in-network physical therapy 
visits. 
 
After the Plan reprocessed your claims, you have been asked to pay 20% coinsurance for the orthosis and a $30 
copayment for the physical therapy visit. 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 cost sharing for the 
orthosis you received on December 24, 2019 and the physical therapy visit you had on December 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept (S0207) provided on March 19, 2019. 
 
You asked the Plan to pay for the paramedic intercept. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S0207 has a status indicator of I 
which is not valid for Medicare purposes. 
 
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 CPT code S0207 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S0207 has a status indicator of I. This means that CPT code S0207 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the paramedic intercept have not 
been met. Therefore, we decided that the Plan does not have to pay for paramedic intercept (S0207) provided 
on March 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided on April 15, 2020. 
 
You asked the Plan to pay for nursing facility care. You say that hospice was terminated on April 8, 2020. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 8, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) defined by codes 
A4595, E0745, L0650, L1851, L2396, L1971, L3170, L3916, L3960 provided to the enrollee on March 25, 
2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. There is no itemized shipping/billing invoice. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for the durable medical equipment (DME) defined by codes A4595, E0745, L0650, L1851, L2396, L1971, 
L3170, L3916, L3960 provided to the enrollee on March 25, 2020.