Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve the continued inpatient mental health services. You say that you would like 
reconsideration because the continued services are medically necessary. The Plan denied your request. The 
Plan says the records describe minimal mental health symptoms and did not document treatment provided in 
past 48 hours that would require continued hospital treatment 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental health 
services. Our reviewer says that it was not expected this enrollee would improve in a reasonable period of time 
beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the member?s condition or for the purpose of diagnosis. Our physician reviewer found based upon review of 
the records provided, this member does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question. 
 
 
 
 
 
 
 
 
 
 
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 continued inpatient mental health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit you had on June 29, 2020. 
 
You asked the Plan to pay for the visit. You say that the doctor only asked you a few questions. The Plan 
denied your request. The Plan says this service is only covered once per year. 
 
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 
copayment for an annual wellness visit once every twelve months.  
 
Review of the file shows that you had an annual wellness visit on June 29, 2020. An annual wellness visit is 
covered once every twelve months. The records also show that you a covered annual wellness visit on February 
28, 2020. This means that the requested visit is your second of 2020, which exceeds the benefit limit. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we 
decided that the Plan does not have to pay for the annual wellness visit you had on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the Aflibercept injection (J0178) rendered by the out of network (OON) 
provider on July 29, 2020 
 
You asked the Plan to pay for this service. 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 service was rendered by an out of 
network provider, without 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. 
 
We reviewed the case file and the Medicare rules. Based upon the documentation provided, we found that the 
Plan has issued a prior authorization for this provider to furnish this service on November 2, 2019. The date 
range for the approval was from September 2019, through September 2021. Additionally, the Plan has not 
addressed the presence of this approval or provided any rationale to suggest it is not valid. Therefore, we 
decided that the Plan has to pay for the Aflibercept injection (J0178) rendered by the out of network (OON) 
provider on July 29, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a cardiology follow up at a tertiary care center. 
 
You asked the Plan to pre-approve the cardiology follow up. You say that you would like reconsideration 
because you do not want to start over with a new cardiologist at a new location. The Plan denied your request. 
The Plan says that you do not require a tertiary level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 cardiology follow up. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found given the multiple procedures at the requested provider, the complexity of the 
repeated catheter interventions and the recent non-STEMI, you do not qualify as having stable disease which 
could allow care to be easily transferred to a new cardiology team. 
 
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 cardiology follow up have been met. Therefore, we decided that the Plan 
has to pre-approve a cardiology follow up at a tertiary care center.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the outpatient emergency appendectomy 
procedure and oral drugs provided during a hospital stay on July 3, 2020. 
 
You asked the Plan to waive the charges for the outpatient surgery and oral drugs. You say that you do not feel 
that you should be charged so much for this procedure because it was an emergency, and you had no chance to 
prepare for this cost. The Plan denied your request. The Plan says although this was an emergency procedure, it 
was still an outpatient surgery provided in the hospital setting for which your EOC clearly states there is 20% 
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 20% 
coinsurance for Medicare-covered hospital visits for outpatient surgery. The Medicare rules also say that Part B 
does not make payment for self-administered drugs provided in the outpatient setting. 
 
You have been asked to pay 20% coinsurance for the outpatient surgery. The outpatient surgery falls within the 
Medicare-covered hospital visits for 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. In addition, the oral drugs provided by the hospital are not 
among those that can be covered by Medicare Part B. Therefore, we decided that the Plan does not have to 
waive the charges for the outpatient emergency appendectomy procedure and oral drugs provided during a 
hospital stay on July 3, 2020.  
 
Benefits for the oral drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve these services. You say that the services should be covered. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prolotherapy. 
 
You asked the Plan to pre-approve prolotherapy. You say that you would like to continue with this 
prolotherapy because it is the only thing that has helped you. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because prolotherapy is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that prolotherapy is not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of prolotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 
prolotherapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
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. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness, congestive heart failure and COPD exacerbation. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lead wires (A4557) provided on September 10, 2020. 
 
You asked the Plan to pre-approve the lead wires. You say that the code in dispute is not inclusive to any other 
codes billed. You say that there is no information that the code in dispute cannot be billed with the other codes 
billed for the same date of service. The Plan denied your request. The Plan says a TENS unit with leads was 
purchased less than 12 months ago. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that providers must furnish sufficient information to 
determine whether payment is due and whether Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The records show that a TENS unit, which included 4 or more leads, 
was provided less than 12 months ago. The records provided did not demonstrate why replacement lead wires 
were medically necessary more often than every 12 months. This means that the provider did not supply 
sufficient information for us to determine whether the coverage criteria were met. Based on this information, 
we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lead wires (A4557) provided on September 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need to regain strength before returning to 
assisted living. The Plan denied your request. The Plan says that your records show you do not currently 
require complex daily nursing care or daily skilled rehabilitation therapy. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have a wheelchair, but prefer to use a 
computer chair, but the computer chair gets stuck on the indentations in linoleum floors. The Plan denied your 
request. The Plan says you are able to use a manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair and you already 
have a manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided between June 16, 
2020, and June 30, 2020. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the home health services 
were 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 pay for the home health care services. Our reviewer 
says that the services were not medically necessary. Our physician reviewer found the documentation does not 
support that the member required skilled nursing services or skilled rehab services to provide treatment that is 
medically necessary. The member did not require skilled nursing or rehab services to effectively provide 
treatment, care, and/or services in order to improve their condition, perform a maintenance program to maintain 
the member?s condition, and/or prevent deterioration. 
 
 
 
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 home health care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health care services provided between June 16, 2020, and June 30, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 3, 2020 to 
April 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal 
Information Processing Standards (FIPS) State and County Code of the place of residence where the home 
health service is delivered with code 85. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct FIPS 
code. 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 pay for the home health services rendered from April 
3, 2020 to April 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance transport provided on May 
22, 2020. 
 
You asked the Plan to reduce the copayment for the ambulance transport. You say that you were told that there 
was a $100 ambulance copayment. You say you should only have to pay what you were quoted. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for each one way Medicare-covered trip.  
 
You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls 
within the ?Ambulance services? 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 reduce the copayment for 
the ambulance transport provided on May 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiogram provided on July 8, 
2020. 
 
You asked the Plan to waive the copayment for the echocardiogram. You say that you feel that you have been 
charged twice. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for diagnostic procedures and tests at an in-network specialist's office.  
 
You have been asked to pay a $40 copayment for the echocardiogram. The echocardiogram falls within the 
'Outpatient diagnostic tests and therapeutic services and supplies' benefit category. Please note, the record 
shows you have a zero balance at this doctor's office. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the echocardiogram provided on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve skin barrier wipes for the enrollee. 
 
You asked the Plan to pre-approve the wipes. You say that the enrollee has the first stage of Alzheimer's. The 
Plan denied your request. The Plan says that these items are not needed for the enrollee's condition, as the 
information submitted does not show an ostomy. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 wipes. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, these items are necessary for daily medical care, and are medically reasonable and 
necessary. This would be an exception to the medical benefit not paying for household items, since these are 
essential to day to day medical 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 the wipes have been met. Therefore, we decided that the Plan has to pre-
approve skin barrier wipes for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) provided on August 17, 2020. 
 
You asked the Plan to pay for the bitewings. You say that you were advised that x-rays were covered once per 
year, with a $0.00 copay. The Plan denied your request. The Plan says this service is not covered by the 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 
among those covered under this benefit. The contract clearly states that the only covered x-rays under your plan 
include complete series of intraoral x-rays (D0210) and panoramic x-ray (D0330). Therefore, we decided that 
the Plan does not have to pay for the bitewings (D0274) provided on August 17, 2020.