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 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 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. While the 
enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility with intermittent 
therapies. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you are not able to take care of yourself and you 
have no one to assist you. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested SNF services do not meet the requirements for approval.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that although you could walk, it is fairly 
painful in your legs to walk, and you would walk to complete errands. The Plan denied your request. The Plan 
says the requested device is not medically necessary as the enrollee is able to walk on her own and you can use 
your four wheeled walker with seat for mobility needs. 
 
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 patients 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 you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or 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 
power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Adhesive bandage, first-aid type, any size, each (A6413). 
 
You asked the Plan to pay for the adhesive bandage. You say that say the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for Adhesive bandage, first-aid type, any size, each (A6413).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease (ESRD)-related lab testing 
provided on September 29, 2021. 
 
You asked the Plan to pay for the ESRD-related lab testing. You say that these lab tests are not included in the 
payment for dialysis. The Plan denied your request. The Plan says for patients receiving dialysis, lab testing 
should be billed to the ESRD facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the end-stage renal disease (ESRD)-related lab testing provided on September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the surgery. You say that you would like to obtain the services from the out-
of-network provider. The Plan denied your request. The Plan says services have been approved with an in-
network provider that provides the same quality of 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 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 
surgery 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 pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you would like to see the out-of-
network provider because you have seen them before. The Plan denied your request. The Plan says an in-
network provider who provides the same quality of service has been approved for the enrollee to have a consult 
with. 
 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services. 
 
You asked the Plan to pre-approve skilled nursing services. The Plan denied your request. The Plan says the 
notes indicate that the enrollee is making little progress. The Plan also says that the enrollee's needs can be met 
at a lower level of care or long-term placement. 
 
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 skilled nursing services. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of skilled nursing services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve skilled nursing services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF is the most appropriate setting for the 
member. You say that the member is a high risk of re-hospitilization if he is discharged to home from the 
LTACH prior to sub-acute rehabilitation. The Plan denied your request. The Plan says there were no noted 
daily skilled complex nursing needs. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that the enrollee has stabilized 
medically and has been receiving skilled rehabilitation services in a long-term acute care hospital 
(LTACH). The enrollee no longer requires daily skilled nursing and/or skilled therapy services.  He could 
benefit from continued intermittent services at a lower level of care. Although the enrollee made slow progress 
with therapy, his functional improvement has plateaued, and there is no indication that transfer to a skilled 
nursing facility is required. He can continue to receive skilled rehabilitation services at the current LTACH or 
be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at a 
LTACH.  
 
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 SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Orthovisc (hyaluronan) injection 
provided on October 21, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were never told that there was a 
copayment for this. You also say that you had a series of three shots and cannot afford a bill for $180. 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 20% 
coinsurance for Part B drugs.  
 You have been asked to pay $59.50, which is 20% of the allowed amount for an injection ($297.48 allowed 
amount x 20% coinsurance = $59.50). An injection falls within the Medicare Part B Prescription Drugs 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 an Orthovisc (hyaluronan) injection provided 
on October 21, 2021. 
 
Your complaint about not being told there was a cost share for the injections 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. You say that you would like reconsideration because the requested 
service is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria 
for coverage. 
 
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 the RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of two diagnostic medial branch blocks (MBBs) with each one providing a 
consistent minimum of 80% sustained relief. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endovenous ablation therapy to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the endovenous ablation therapy. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says there 
are in-network providers available. 
 
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 endovenous ablation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D1110, D0120, D2392) provided November 
29, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the plan has covered the required amount. The services were out-of-network and 
the correct cost-share was applied. 
 
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 plan contract states there is a 70% 
coinsurance for dental services received out-of-network. The services were provided by a non-contracted provider. The correct cost sharing was applied. Therefore, we decided that the Plan does not have to pay for 
dental services (D1110, D0120, D2392) provided November 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
23, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not have an 
ambulance ride that day. You also say that after falling, all the emergency medical technician (EMT) did was 
help you get back up. 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 $225 
copayment for ambulance services. The contract also says that the copayment applies for evaluation, treatment, 
or transportation to the hospital.  The ambulance records shows that you were evaluated by the EMTs on November 23, 2021. Even though you 
were not transported in the ambulance, you were evaluated, and a cost share applies. You have been asked to 
pay a $225 copayment for ambulance services. Ambulance services 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 waive the copayment for ambulance services provided on 
November 23, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the Reblozyl (J0896). 
 
You asked the Plan to pre-approve the Reblozyl. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says that the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Reblozyl. Our reviewer says that the 
enrollee meets criteria for coverage of the requested drug, Reblozyl. Our physician reviewer found CMS-
approved clinical research supports the use of Reblozyl for the members condition of low-risk 
Myelodysplastic Syndromes without ringed sideroblasts. 
 
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 Reblozyl have been met. Therefore, we decided that the Plan has to pre-
approve the Reblozyl (J0896).  
 
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 porcelain/ceramic crown (D2740) and core buildup 
(D2950) provided on November 12, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that these services should have been 
covered by your medical benefits. The Plan denied your request. The Plan says these services are not covered 
by your 2020 dental benefit. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
porcelain/ceramic crown (D2740) and core buildup (D2950) provided on November 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the head/brain. 
 
You asked the Plan to pre-approve a CT scan of the head/brain. You say that a CT scan is medically necessary. 
The Plan denied your request. The Plan says a CT scan is not medically necessary. 
 
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 of the head/brain. Our 
reviewer says that a CT scan of the head/brain is not medically necessary. Our physician reviewer found the 
neurosurgeon's notes clearly indicate the plan of a follow up MRI, which has been approved by the Plan on 
January 11, 2022. There are no results of the MRI in the records. If the clinician has decided to do a CT instead 
it is not reflected in the submitted records and if desired the MRI order needs to be cancelled and a new 
authorization of a CT of the brain needs to be substituted. 
 
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 of the head/brain have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CT scan of the head/brain.