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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for an admission to 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving gradually and still requires short term 
monitoring and treatment but is likely to not require more than 24 additional days of acute care services which 
can be completed at the current setting. The enrollee does not require services at the LTACH that are not 
already available at the current hospital. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current setting. Therefore, this request for LTACH services is not 
justified and will be considered not medically necessary at this time. Transfer to a lower level of care may be 
considered when treatment has finished. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extracapsular cataract extraction 
removal with insertion of intraocular lens prosthesis (66984) provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you feel the copayment 
should be picked up by Medicaid because they are secondary to Medicare. The Plan denied your request. The 
Plan says this claim was processed with the correct copayment 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 $300 
copayment for ambulatory surgical center and outpatient hospital visits for Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay $300 copayment for the cataract surgery. The cataract surgery falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 the extracapsular cataract 
extraction removal with insertion of intraocular lens prosthesis (66984) provided on July 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment charged for ambulance transport provided on 
October 25, 2019. 
 
You asked the Plan to waive this copayment. You say that you were told there would not be a copayment. The 
Plan denied your request. The Plan says this copayment was charged based on the service provided and the 
Plan contract. 
 
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 $100 
copayment for each one-way ambulance transport. 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 charged for ambulance 
transport provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerebral Perfusion Analysis (0042T) performed June 
21, 2020. 
 
You asked the Plan to pre-approve the Cerebral Perfusion Analysis. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Cerebral Perfusion Analysis is non-covered by 
Medicare.  
 
We looked at the file and Medicare rules. The service at issue is not a covered service. Based on this 
information, we decided that Medicare rules for coverage of the Cerebral Perfusion Analysis have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Cerebral Perfusion Analysis (0042T) 
performed June 21, 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. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to LTACH is needed for 
medical management and therapies to return to maximum PLOF. The Plan denied your request. The Plan says 
admission to LTACH was denied as not meeting criteria, not medically necessary and continued acute hospital 
stay was offered until the member could discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted to the current acute care hospital with acute respiratory 
status related to COVID-19 pneumonia. He was treated with BiPAP, oxygen, remdesivir, dexamethasone, and 
convalescent plasma. The course was complicated by acute kidney injury and coagulopathy. Recent notes show 
that the enrollee is more stable with acute kidney injury resolved, hyperkalemia resolved, hyponatremia 
resolved but still dependent on high flow oxygen and BiPAP. The enrollee appears to be improving gradually 
but is likely to not require more than 24 additional days of acute care services which can be completed at the 
current setting. The enrollee does not require services at the LTACH that are not already available at the 
current hospital. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current setting. Therefore, this request for LTACH services is not justified and will be 
considered not medically necessary at this time. Transfer to a lower level of care may be considered when 
treatment has finished. 
 
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 pre-approve the ophthalmologist visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmologist visit. You say that you are not satisfied with the care 
provided by an in-network provider. The Plan denied your request. The Plan says there are additional in-
network providers available to treat your condition. 
 
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 
the ophthalmologist visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99213) provided on May 27, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services by an 
out-of-network provider. 
 
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 office outpatient visit (99213) provided on 
May 27, 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 foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is for arch support. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral back brace (L0650) 
received on May 7, 2020. 
 
You asked the Plan to waive the coinsurance for a lumbar-sacral back brace. You say that you were told by a 
representative of the provider that your copayment would be $150. The Plan denied your request. The Plan says 
the correct coinsurance was 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 20% 
coinsurance for Medicare-covered durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for a lumbar-sacral back brace. A lumbar-sacral back brace falls 
within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a lumbar-sacral back brace (L0650) received on May 7, 2020.  
 
Your complaint about receiving erroneous or ambiguous information regarding your cost-sharing 
responsibilities from a representative of the provider is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99213) provided on May 14, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you were unaware the provider was out-of-network. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 office outpatient visit (99213) provided on 
May 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory viral testing provided on April 27, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says respiratory 
viral panels of 6 or more pathogens are non-covered. 
 
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 documentation does not show that the testing was ordered after 
common conditions were ruled out. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory viral testing provided on April 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 24, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT), lower extremity; without 
contrast material scan. 
 
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no indication for a CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that a CT 
scan is not medically reasonable and necessary in this case. You have chronic right hip pain. The CT of the 
right lower extremity from August 28, 2020 showing mild osteoarthritis and a 4mm subchondral cyst at the 
root of the right acetabulum. A recent progress note does not state any flare-up of pain, any new abnormal 
findings, or planned procedure which might warrant imaging of the hip again. Our physician reviewer found 
that your condition does not meet Medicare criteria for a CT scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT), lower extremity; without contrast material scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Gel-One 30mg/3ml syringe for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc and don't require 
prior authorization. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed one viscosupplemental treatment such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires that one of these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Gel-One is not approved as step 
criteria have not been met. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Gel-One 30mg/3ml syringe for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on May 28, 
2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid in full. The Plan denied 
your request. The Plan says those services not directly related to manual manipulation of the spine are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided to the enrollee on May 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on October 
15, 2019. 
 
You asked the Plan to pay for the ambulance transportation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on 
October 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the services provided on 
May 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an x-ray (73630) and office visit (99213) 
provided January 16 and March 2, 2020. 
 
You asked the Plan to waive the copayments for the x-ray and office visit. You say that the copayments should 
be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 $14 
and $35 copayment for x-rays and specialist visits.  
 
You have been asked to pay a $14 and $35 copayment for the x-ray and specialist office visit. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayments for an x-ray (73630) and office visit (99213) provided January 16 and 
March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the upper extremity. 
 
You asked the Plan to pre-approve an MRI of the upper extremity. You say that the requested MRI of the upper 
extremity is medically necessary. The Plan denied your request. The Plan says the requested MRI of the upper 
extremity is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the upper extremity. Our 
reviewer says that the requested MRI of the upper extremity is not medically necessary. Our physician reviewer 
found the enrollee is with new or changed musculoskeletal signs and/or symptoms. Based on the 
documentation provided, criteria have not been met. There is no routine x-ray documented. The requested MRI 
is not needed at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the upper extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an MRI of the upper extremity.