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

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to see your old primary care 
physician. 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 
an office visit to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye exam (S0620), eyeglass frames (V2020) and 
sphere lenses (V2200) provided on April 8, 2021. 
 
You asked the Plan to pay for an eye exam, frames and sphere lenses. You say that you disagree with the denial 
and would like reconsideration. The Plan denied your request. The Plan says you received services for 
outpatient services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is obtained through one of the Plan's routine vision service 
vendors. 
 
We looked at the file and the Plan's rules. These services are not covered if performed by a provider that is not 
part of the Plan's vision service vendors. The records show that the services at issue were provided by an out-
of-network provider. Based on this information, we decided that the Plan's rules for coverage of an eye exam, 
frames and sphere lenses have not been met. Therefore, we decided that the Plan does not have to pay for a 
routine eye exam (S0620), eyeglass frames (V2020) and sphere lenses (V2200) provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) with a 
connection (E2311) and a faster motor upgrade (K0108). 
 
You asked the Plan to pre-approve a power seat elevation system with a connection and a faster motor upgrade. 
You say that these items are medically necessary. The Plan denied your request. The Plan says these items are 
not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described 
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power 
standing feature, it will be denied as non-covered.  
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300) with a connection 
(E2311) and a faster motor upgrade (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.  

You asked the Plan to pre-approve additional visits. You say that the enrollee remains a fall risk. The Plan 
denied your request. The Plan says the required services do not need to be performed by a qualified therapist.  

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  

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 additional visits. Our physician 
reviewer found that the enrollee has muscle weakness, with unsteadiness on her feet and difficulty walking. 
The enrollee has had 21 outpatient therapy visits. The plan denied the 12 additional physical therapy visits. The 
clinical records do not demonstrate that 12 additional physical therapy visits with a professional therapist are 
required to safely and effectively provide treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the enrollee will benefit from subacute rehab 
that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the plan has 
no contractual obligation to cover services that are not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not 
reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The 
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination 
of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary 
services on an inpatient basis, in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like a second opinion. 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 
physician services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that there are some things you cannot do that you would 
need assistance with so a nursing facility physical therapist would be very helpful. You state you live alone so 
you would hate to put yourself in any danger. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are 
consistently ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal 
supervision. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton therapy. 
 
You asked the Plan to pre-approve proton therapy. You say that you would like reconsideration because the 
requested therapy is medically necessary. The Plan denied your request. The Plan says the use of this therapy 
for the member's condition is considered 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 proton therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found guidelines recommend against routine use of proton therapy. This therapy would arguably 
exceed the member's 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 proton therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton therapy.
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 inpatient rehabilitation is medically necessary for 
this enrollee. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met. 
The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  

While the documentation does support a need for physical and/or occupational therapy, there is no documented 
need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 
enrollee 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 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 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

There is not a reasonable expectation that this enrollee 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 acute inpatient rehabilitation facility (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. The Plan denied your request. The Plan says the 
records do not support the need for the services. 
 
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.

The file shows that 8 home health physical therapy and 8 home health skilled nursing visits were requested. 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 physician 
reviewer found that the enrollee is unable to stand. She is dependent for activities of daily living. She does not 
have documented skilled nursing needs. She does not have documented skilled therapy needs. Her needs appear 
to be custodial. As such, the requested home health services are not shown to be medically necessary or 
reasonable. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 1, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that you do not agree with your responsibility on this 
claim. You also say you would like the claim to be reprocessed and paid. The Plan denied your request. The 
Plan says the service at issue is not a covered benefit. 

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed as a routine eye exam by a participating provider. 
 
We looked at the file and the Plan's rules. An eye refraction is only covered by the Plan when it is performed as 
a routine eye exam. The eye refraction was performed as part of a medical vision exam, and therefore is not a 
covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) 
provided on April 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve aide services. You say that you cannot do activities of daily living. The Plan 
denied your request. The Plan says a home health aide is not covered when requested alone. 
 
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.  
 
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 aide services. Our physician reviewer 
found that you do not have documented skilled nursing or therapy needs. As such, home health aide services 
are not shown to be medically reasonable or 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 aide services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the $375 copayment charged for outpatient surgery provided 
from March 25, 2021, to March 26, 2021. 
 
You asked the Plan to waive this copayment. You say that you were an inpatient and this cost share is 
incorrect. The Plan denied your request. The Plan says this copayment was charged based on the services 
provided and the Plan contract agreement. The rules say a plan must disclose to its enrollees in clear, accurate 
terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract 
with the Plan clearly says that enrollees must pay $375 copayment for outpatient surgery.

You have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the $375 copayment charged for outpatient surgery provided from March 25, 2021, to 
March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered for 
enrollees who are insulin treated. 

There is no evidence of insulin treatment in this case. Based on this information, we decided that Medicare 
rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from May 12, 2020, 
through May 20, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to pay 
for these charges. The Plan denied your request. The Plan says the copayment was 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 $492 
copayment per day for days 1-4 for inpatient hospital care.  
 
You have been asked to pay a $492 copayment per day for days 1-4 for inpatient hospital care. The service at 
issue falls within the inpatient hospital care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for inpatient hospital care from May 12, 2020, through May 20, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for the collection of a blood specimen from a completely 
implantable venous access device (36591) provided on May 18, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the service provided. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for the collection of a blood specimen from an implantable venous access 
device.  
 
We looked at the file and your contract with the Plan. Based on this information, we find that you did not have 
a reasonable expectation that the blood draw through your implanted venous access device would be 
considered a surgical procedure. While this service may be coded as surgical, the performance of the service 
would not include many of the components that would reasonably be considered surgery by a layperson. There 
is no other benefit category in the EOC under which this service would be included other than lab testing. 
Because of this ambiguity, we find that you cannot be asked to pay more than a $0 copayment for the service at 
issue. Therefore, we decided that the Plan has to waive the copayment for the collection of a blood specimen 
from a completely implantable venous access device (36591) provided on May 18, 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.