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

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on May 2, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you are requesting that this claim be 
reconsidered for your physician and the denial be overturned. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 subsequent hospital care provided on May 2, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health and home physical therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says criteria 
for admission to the LTACH 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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. Our reviewer found that there are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the 
Health Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 29, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 physician's services provided on October 29, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the diagnostic ultrasound provided on August 7, 
2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you do not feel that any kind of 
image or x-ray was done. The Plan denied your request. The Plan says the claim was processed 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 $55 
copay for each Medicare-covered standard x-ray and ultrasound.  
 
You have been asked to pay a $55 copay for the services provided. The services fall within the outpatient 
diagnostic tests 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 copay for the diagnostic ultrasound 
provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental x-rays with dental codes D0220 and D0230 
provided on July 7, 2020. 
 
You asked the Plan to pay for dental codes D0220 and D0230. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
under your supplemental dental 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 dental x-rays with dental codes 
D0220 and D0230 are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the dental x-rays with dental codes D0220 and D0230 provided on July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided September 3, 2019. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 G0483 is not supported in the medical record. Specifically, the service date on the 
records do not match the date of service on the claim submitted. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (G0483) provided September 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trastuzumab. 
 
You asked the Plan to pre-approve Trastuzumab. You say that targeted therapy may improve survival for 
endometrial carcinoma. The Plan denied your request. The Plan says this medicine alone is not supported for 
the enrollee's condition. 
 
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 trastuzumab. Our reviewer says that 
Trastuzumab is not FDA approved for the treatment of endometrial cancer. Our physician reviewer found that 
the enrollee has a mixed serous and small cell that is HER2 equivocal and would not meet criteria for 
treatment. Therefore, Trastuzumab is 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 trastuzumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trastuzumab.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery services provided on 
September 17, 2019. 
 
You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan 
says benefits were 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 0% or 
20% coinsurance for outpatient surgery.  
 
You have been asked to pay a 20% coinsurance for the services provided. The services fall within the 
outpatient surgery 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 cost share for the outpatient surgery 
services provided on September 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits for physical therapy. 
 
You asked the Plan to pre-approve the home health services. You say that you are requesting in home physical 
therapy. You say that you cannot move yourself around in your wheelchair. You say that you need someone to 
move you around. You also say that you need to be able to move from one place to another by yourself. The 
Plan denied your request. The Plan says you have not been seen or evaluated by a physician for the home 
health visits. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met as this service has not been ordered by a physician. 
Therefore, we decided that the Plan does not have to pre-approve home health visits for physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses from a non-plan provider. 
 
You asked the Plan to pre-approve the requested services. You say that your current glasses are causing strain 
on your eyes. The Plan denied your request. The Plan says there are in-network providers who can provide the 
necessary services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. 
 
We looked at the file and the rules. The requested provider is not a network provider with the plan. The Plan 
has network providers available. We found no exception which would require the plan to provide the requested 
eyeglasses from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve 
eyeglasses from a non-plan provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical, multiple post collar, occipital/mandibular supports 
(L01870) provided October 6, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the medical records and doctor's order clearly 
demonstrate medical necessity for the devices prescribed. The Plan denied your request. The Plan says the 
records do not support the service billed. 
 
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, itemized delivery ticket, itemized shipping invoice or 
relevant medical records which support medical necessity 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 cervical, multiple post collar, occipital/mandibular supports 
(L01870) provided October 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ERLEADA tablets. 
 
You asked the Plan to pre-approve ERLEADA tablets. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by Medicare 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 pre-approve ERLEADA tablets.  
 
Benefits for ERLEADA tablets 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Tobramycin 300mg/5ml solution. 
 
You asked the Plan to pre-approve the tier exception. You say that the drug is medically necessary and the tier 
exception should be approved. The Plan denied your request. The Plan says tier exceptions are not available for 
Part B benefits. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for a tier 
exception have not been met. Specifically, the drug is being requested under Medicare Part B. Part B Drugs are 
not eligible for a tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier 
exception for Tobramycin 300mg/5ml solution.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TENS unit lead wires provided on September 27, 2020. 
 
You asked the Plan to pay for lead wires (A4557). You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says it has not been 12 months since the enrollee received the TENS device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee received a new purchased TENS device on November 
27, 2019. There is no documentation in the file as to why the lead wires needed to be replaced before 12 
months' time. Based on this information, we decided that Medicare rules for coverage of lead wires (A4557) 
have not been met. Therefore, we decided that the Plan does not have to pay for the TENS unit lead wires 
provided on September 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
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. 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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that you have been using insulin 
multiple times (3 or more) a day. You are not on insulin but is on metformin and glipizide. 
 
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 a continuous glucose monitor and supplies.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for a diagnostic mammography (77065) provided on July 
10, 2020. 
 
You asked the Plan to hold you harmless for a diagnostic mammography. You say that this should be covered. 
The Plan denied your request. The Plan says that you had a screening mammogram within the last year. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules also say that the term "screening mammography" means a radiologic 
procedure provided to an asymptomatic woman for the purpose of early detection of breast cancer and includes 
a physician's interpretation of the results of the procedure.  Unlike diagnostic mammographies, there do not 
need to be signs, symptoms, or history of breast disease in order for the exam to be covered. 
 
You were provided a diagnostic mammography by a contract provider. The file does not show that the Plan 
provided notice that a diagnostic mammography would not be covered. While the Plan disclosed limitations on 
screening mammographies, this was billed as a diagnostic service. Under Medicare rules, this means a 
diagnostic mammography is considered approved by the Plan. Therefore, we decided that the Plan has to hold 
you harmless for a diagnostic mammography (77065) provided on July 10, 2020.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve Restasis. The Plan denied your request. The Plan says this medication does 
not fall under 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 pre-approve Restasis.  
 
Benefits for Restasis 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the outpatient surgery services provided 
from November 12, 2019, to November 13, 2019. 
 
You asked the Plan to waive the cost shares for the surgery services. You say that the plan cannot come up with 
a percentage from nothing. The Plan denied your request. The Plan says the claim processed with the correct 
coinsurance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for surgery performed at an outpatient hospital facility.  
 
You have been asked to pay 20% of the Medicare-allowed amount for the surgery services. The services fall 
within the outpatient surgery 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 cost shares for the 
outpatient surgery services provided from November 12, 2019, to November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you collapsed at home. You say that while 
in the hospital you have only been able to stand and take a few steps with a 2 person assist. You say that your 
family is concerned with you going home alone due to weakness and safety concerns. You also say that your 
family cannot assist at this time. The Plan denied your request. The Plan says you do not require complex daily 
nursing care that must be provided in a skilled nursing facility. The Plan also says that you do not require daily 
skilled rehabilitation therapy at this time. 
 
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 the SNF admission. Our reviewer says 
that the enrollee did not meet the Medicare criteria for an SNF admission. Our physician reviewer found the 
enrollee does not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.