Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for leg pain and had 
surgery for treatment of a pathologic leg fracture. The enrollee's medical problems are stable. There are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on February 22, 2019. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says this 
service requires prior authorization from non-par providers and there are no medical records or clinical 
documentation for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   
 
We looked at the file and Medicare rules. The file shows that the provider did not submit sufficient information 
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the 
physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy services provided on February 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on February 26, 
2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for 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 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 out of network physician services provided on February 26, 
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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says that the enrollee's complex medical needs are 
being met in the current acute setting at this time. 
 
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. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include intravenous antibiotics, surveillance laboratory studies, total parenteral nutirition, oral 
medications, and therapy services. The documentation does not support that the enrollee in this case requires 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
   
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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care provided on July 29, 2019, by 
an OON provider. 
 
You asked the Plan to pay for the initial nursing facility care. You say that the treating provider depends upon 
the hospital staff to verify eligibility, and to obtain the proper authorization from the enrollee's insurance 
company. You also say that medically necessary services were provided to the enrollee in good faith. The Plan 
denied your request. The Plan says the treating provider is a non-network provider who does not work with the 
enrollee's health plan. The Plan also says that the enrollee was referred by her non-participating outpatient 
nursing facility. 
 
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 initial nursing facility care provided on July 
29, 2019, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the prophylaxis (D1110) provided on August 2, 2019. 
 
You asked the Plan to pay for the prophylaxis. You say that you confirmed that the provider in this case was in 
network multiple times. You say that you received a denial letter with a different provider that you did not see. 
The Plan denied your request. The Plan says prophylaxis is covered once every 6 months. The Plan also says 
that the frequency limit has been exceeded. 
 
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 and prophylaxis is listed as a covered 
service, the frequency limit of once every 6 months has been exceeded. The record shows that the Plan paid for 
a cleaning on November 26, 2019. Therefore, we decided that the Plan does not have to pay for  the 
prophylaxis (D1110) provided on August 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy (inject liquid or foam into a varicose vein) 
(36465, 36466). 
 
You asked the Plan to pre-approve sclerotherapy. You say that you are being denied on a previously approved 
procedure. You can barely walk and would like this approved so you can receive the treatments. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for coverage as your doctor wants to 
treat varicose veins that are between 4.4 and 7.4 millimeters in diameter. Coverage cannot be approved for 
veins larger than 4 millimeters in diameter. 
 
  
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. Based on this information, we decided that Medicare rules for 
coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
sclerotherapy (inject liquid or foam into a varicose vein) (36465, 36466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve eye procedure. You say that you already have compromised vision and 
could lose your remaining eyesight. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because the requested provider is out-of-network with the Plan and this procedure is 
experimental/investigational. 
 
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. You can be treated by an in-
network provider. 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 the medical services to be provided by an out 
of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on April 3, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was 
not billed in accordance to the guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim provided does not show the services were billed according to 
Medicare guidelines. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on 
April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services provided by an out of network 
(OON) provider on June 10, 2019. 
 
You asked the Plan to pre-approve the OON medical services. You say that the enrollee requires care from a 
provider able to treat her in the nursing home. The Plan denied your request. The Plan says no request for 
authorization was made for these non-emergent services. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve the medical services provided by an out of network (OON) provider 
on June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve these 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic right knee pain 
and osteoarthritis on x-ray. The requested genicular nerve blocks are considered experimental/investigational in 
nature and are the subject of ongoing clinical trials. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) provided on 
July 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the behavioral health services. You say that you though the doctor was 
participating with the plan. The first office you went to was booked and she was able to take you. That's why 
you went with her and thought your coverage would be good. 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 integrated biopsychosocial assessment (90791) 
provided on July 6, 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 heavy duty manual wheelchair (CPT Code K0006) and 
the other requested items/accessories. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not 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 DME. Our physician reviewer 
found the documentation does not support that you meet all of the criteria for coverage in LCD L33788 for the 
heavy duty manual wheelchair (CPT Code K0006) and the other requested items/accessories. The 
documentation indicates you have a mobility deficit but there are no clear physical examination medical 
progress reports with a detailed neuromuscular exam or gait evaluation that support this. The documentation 
does not indicate details of your home and whether it provides adequate access for the requested wheelchair. 
The documentation is not clear that a manual wheelchair will significantly improve your ability to participate in 
MRADLs and you will use it on a regular basis in the home. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve heavy duty manual wheelchair (CPT Code K0006) and the other requested items/accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral sleep apnea appliance.
You asked the Plan to pre-approve the oral sleep apnea appliance. The Plan denied your request. The Plan says the enrollee 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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an oral sleep apnea appliance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910).
You asked the Plan to pre-approve the periodontal maintenance. You say that when you scheduled this service, you made sure it would be covered. You also say that you were told that the dentist requesting the service is not in your Plan's network, and you feel that this should be covered. The Plan denied your request. The Plan says this service is not covered by Medicare under any normal circumstances.
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 periodontal maintenance (D4910).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for 4 inpatient acute or inpatient rehabilitation 
admissions on March 9 to March 26, 2020. 
 
You asked the Plan to waive the copayments for 4 inpatient acute or inpatient rehabilitation admissions. You 
say that the Plan should consider these 4 admissions as a single hospital stay. The Plan denied your request. 
The Plan says the correct copayments were applied. 
 
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 $250 
copayment for each day of days 1-5 for a Medicare-covered stay in a network hospital. The contract also says 
that this cost-share applies each time you are admitted to an inpatient hospital. 
 
You have been asked to pay copayments totaling $3,000 for 4 inpatient acute or inpatient rehabilitation 
admissions. Inpatient acute or inpatient rehabilitation admissions fall 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 copayments for 4 inpatient acute or inpatient 
rehabilitation admissions on March 9 to March 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve 22 additional routine transports. 
 
You asked the Plan to approve these services. You say that you had a knee replacement and need transportation 
to physical therapy appointments. The Plan denied your request. The Plan says you have exhausted the benefit 
limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to approve 22 additional routine transports.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home blood draw services. 
 
You asked the Plan to pre-approve the requested services. You say that you are not able to walk from the car to 
the lab. The Plan denied your request. The Plan says you are not confined to your home. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home blood draw services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on March 21, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that you disagree with the denial. The Plan denied 
your request. The Plan says prior authorization must be obtained. 
 
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 therapeutic exercises (97110) provided on 
March 21, 2019 by an out of network (OON) provider.