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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not 
meet Medicare criteria for coverage of the requested IRF 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 the complexity of the member's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  It is not clear 
that the enrollee can fully participate in and benefit from at least 3 hours a day /5 days a week, or 15 hours over 
7 consecutive days, of therapy services. There is not a reasonable expectation that this member 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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be 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 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 there are no acute rehabilitation or nursing needs identified in the records.  
 The enrollee is medically stable and does not need PM&R physician supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At 
the current mobility status and his fatigue level as described above, the enrollee does not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach to daily therapy in an IRF. The enrollee's rehab needs can be met safely at a lower intensity and 
alternate setting such as in a skilled nursing facility (SNF). 
 
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/hospice aide (G0156 x9) and skilled 
nursing services (G0299 x5). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provided information does not support the need for a home health aide or a skilled 
nurse to make more visits. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary.  
 Our physician reviewer found the documentation does not support that skilled nursing or skilled therapy 
services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, or to establish/perform a maintenance program to maintain your condition and/or prevent 
deterioration, beyond those approved by the plan. The documentation does not support that home health aide 
services are reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled 
professional staff beyond those approved by the plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health/hospice aide (G0156 x9) and skilled nursing services (G0299 x5).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmologist services (92014, 92134) provided on 
October 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmologist services. You say that you have seen these doctors more than 
once and have argued about the bill. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan and the services were not referred by a network provider or rendered in a participating 
facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor 
were they approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 ophthalmologist services (92014, 92134) provided 
on October 8, 2021, by an out-of-network (OON) provider.  
 
Your complaint about the potentially poor customer services you received from the Plan 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 waive the deductible for the duplex scan you had on September 17, 
2021. 
 
You asked the Plan to waive the deductible for the duplex scan. You say that no deductible should have applied 
to this service. The Plan denied your request. The Plan says you were assessed this deductible correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to radiological diagnostic services.  
 
The duplex scan is a radiological diagnostic service. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible which applies to radiological diagnostic services. This 
cost sharing is a contractual obligation that had not been met at the time the duplex scan was received on 
September 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the duplex 
scan you had on September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services for dental care provided on 
June 7, 2021. 
 
You asked the Plan to pay for the emergency room services for dental care. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 services are not covered by the enrollee's medical benefit because 
they were services involving the care, treatment, filling, removal or replacement of teeth or structures directly 
supporting the teeth. Therefore, we decided that the Plan does not have to pay for the emergency room services 
for dental care provided on June 7, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollees medical conditions are stable with no issues that require a physicians 
evaluation three or more times per week. As of March 9, 2022, she is reported to be doing very well with 
minimal pain, pain is well controlled. Her physical examination, vital signs and reported laboratory testing 
showed no signs of encephalopathy, sepsis or renal failure. Her sick sinus syndrome, hypertension and atrial 
fibrillation also appear stable. The enrollee does not require the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be 
appropriate in this case. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on August 11, 
2021. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that the services should be 
covered as all you did was get your nails cut. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services 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 clearly says that you must pay a $45 
copayment for Podiatry services.  
 
 
 
 
 
 You have been asked to pay a $45 copayment for podiatry services. 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 podiatry services provided on August 11, 2021.
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 this is needed to help enrollee needing to regain 
maximum function. The Plan denied your request. The Plan says the services required which include therapy 
can safely be received at a different setting. 
 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 there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for 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 waive the copayment for the office visit you had with a pulmonology 
specialist on January 13, 2021. 
 
You asked the Plan to waive the copayment for the pulmonology visit. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $50 
copayment for visits with a Tier 2 specialist.  
 
You have been asked to pay a $50 copayment for the pulmonology visit. The pulmonologist you saw is a Tier 2 
specialist with your plan. 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 office visit you had with a pulmonology 
specialist on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that 
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water 
and/or phone bill payments (debit card), home assistance services (repairs). 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes 
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or 
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan 
says the certification dated February 10, 2022 documented that the enrollee has none of the qualifying 
diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for 
adverse health outcomes. 
 The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you 
must have one or more comorbid and medically complex chronic conditions that are life-threatening or 
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization 
or other adverse health outcomes; and must require intensive care coordination.  
 
We looked at the file and the Plans rules. The file shows that your medical conditions are not eligible medical 
conditions for coverage under the Plans benefit. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, 
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home 
assistance services (repairs).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out-of-network chiropractic services 
provided from September 29, 2021, to December 16, 2021. 
 
You asked the Plan to waive the deductible for the out-of-network chiropractic services. You say that the 
services should be covered. The Plan denied your request. The Plan says the deductible applied correctly based 
on the contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,500 out-of-network deductible which applies to Chiropractic 
services.  
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the benefit category Chiropractic 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 out-
of-network deductible which applies to Chiropractic services. This cost sharing is a contractual obligation that 
had not been met at the time the out-of-network chiropractic services was received on September 29, 2021 to 
December 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for out-of-
network chiropractic services provided from September 29, 2021, to December 16, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee does not require at least 3 hours a day/5 days a week, or 15 hours over 7 
consecutive days, of therapy services. The enrollee is not reasonably expected to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Therapy services may 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgical services (64612) 
provided on March 12, 2021, and June 18, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgical services. You say that you were told you 
would be charged a $35 copayment. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 $295 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  You have been asked to pay $485.18, which is less than your copayment for two outpatient surgical services 
($242.59 allowed amount x 2). Outpatient surgical services fall within the Outpatient Surgery and Other 
Medical 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 outpatient surgical services (64612) provided on March 12, 
2021, and June 18, 2021.