Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency air ambulance transport (A0430). 
 
You asked the Plan to pre-approve non-emergency air ambulance transport. You say that the enrollee has an 
unusual disease and needs to be treated. The doctor that will be treating the enrollee is in another state so the 
enrollee needs to be transported by air ambulance. The Plan denied your request. The Plan says this enrollee is 
stable in her current living level of care. She does not have a life-threatening condition requiring air ambulance 
transportation. This is not the closest facility for which care (when medically necessary) can be delivered. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 non-emergency air ambulance 
transport. Our reviewer says that the non-emergency air ambulance transport is not medically necessary. Our 
physician reviewer found that the documentation does not support that the patient suffers from an illness or 
injury that contraindicates transportation by any means other than ambulance. Records did not reveal any 
contraindication to the enrollee moving to California via regular air transport (commercial airlines, not 
ambulance). The documentation does not support that the enrollees condition is such that the time needed to 
transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollees 
survival or seriously endangered the enrollees health. The enrollee was not described as needing urgent 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency air ambulance transport have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency air ambulance transport (A0430).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) psychotherapy 
services provided on November 5, 2021. 
 
You asked the Plan to waive the copayment for the OON psychotherapy services. You say that you were 
informed that the provider was in-network. 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 $55 
copayment for each therapy visit with an out-of-network provider.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the OON psychotherapy services. The OON psychotherapy services fall within the 
Outpatient Mental Health Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
out-of-network (OON) psychotherapy services provided on November 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get the therapy services. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 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 supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 based on the medical records provided there is concern that the enrollee will not be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his reported level of weakness and decreased endurance with therapy. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 30, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were given no 
choice and the provider called for the ambulance. The Plan denied your request. The Plan says the proper 
copayment was applied for the service that was rendered. 
 
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 each Medicare-covered emergency ambulance service (one-way).  
 
  You have been asked to pay a $295 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Transport 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 ambulance transportation provided on December 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need this 
transportation to get to your doctor's appointments. The Plan denied your request. The Plan says that this 
request exceeds limits set in the subscriber agreement. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 28, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you do not know what the bill is for. 
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 $90 
copayment for emergency room visits.  
 
The file shows that you were evaluated and treated at the emergency room on November 28, 2021. Therefore, 
you have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on November 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) and the therapeutic 
activities (97530) provided on March 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for 
these services. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation. However, the Plan offers a chiropractic benefit that exceeds Medicare coverage. For that reason, 
the Plans coverage rules apply in this case. The Plan covers unlimited routine chiropractic visits per plan year. 
The Plan pays up to $750 per plan year for these services. 
 
We reviewed the case file and the Plans rules. Based on this information, we find that the Plans rules for 
coverage of the services provided have not been met. Specifically, the Plan contract states that you are covered 
up to $750 for routine chiropractic visits. The Plan has issued payment in the amount of $750 for previous 
routine chiropractic services provided to you this calendar year. Therefore, you have exhausted the allowable 
benefit for these services. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises 
(97110) and the therapeutic activities (97530) provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (head, foot and height 
adjustments), with any type of side rails, with mattress (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee is unable to transfer 
himself from his current bed to his power chair. He is at risk for falls/injury. He has also been contacting EMS 
nearly every day to help him transfer. He has a history of stroke resulting in his right side being affected. He 
also has been experiencing weakness in his left arm. He has been evaluated in the home by occupational 
therapy and in the office. All agree that a hospital bed could resolve the mobility/safety/utilization issues for 
him. The Plan denied your request. The Plan says the requested item is not a covered benefit with your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (head, foot and height adjustments), with any type of side rails, with mattress (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (K0861). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested item have not been met. 
 
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.  
 
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 Group 3 power wheelchair. Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient clinical documentation in terms of the enrollees functional status and physical examination findings. The power wheelchair evaluation indicates that the enrollee has 4-5/5 motor 
strength in the upper and lower extremities. There is no information regarding the enrollees range of motion 
and spasticity in the extremities. There is also limited functional history provided. 
 
The in-home power mobility assessment does indicate that the enrollee needs assistance with activities of daily 
living. However, it does not indicate to what degree the enrollee requires assistance, specifically with regards to 
transfers and mobility. The appeal letter indicates that the enrollee does not have the strength and endurance to 
propel a manual wheelchair or adequately perform pressure relief. However, there again is no additional 
clinical information provided in terms of the enrollees actual physical examination findings and function. 
 
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 Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day CGM sensor. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet prior 
authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14-day CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre 14-day continuous glucose monitor (CGM) sensor (K0553).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) psychotherapy 
services provided on November 10, 2021. 
 
You asked the Plan to waive the copayment for the OON psychotherapy services. You say that you were 
informed that the provider was in-network. 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 $55 
copayment for each therapy visit with an out-of-network provider.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the OON psychotherapy services. The OON psychotherapy services fall within the 
Outpatient Mental Health Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
out-of-network (OON) psychotherapy services provided on November 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member has no skilled nursing needs, and the physical and 
occupational therapy could be provided at a lower level of service. 
 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 
SNF services are not medically reasonable and necessary. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is not shown to have 
an acute decline in function. Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided at a lower level of care. Our physician reviewer found that 
the enrollee's 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on November 21, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for OON services have not 
been met. 
 
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 anesthesia services provided on November 21, 
2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for foot inserts on December 31, 2021. 
 
You asked the Plan to waive the copayment for a foot insert. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the coinsurance applied is 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 20% 
coinsurance for foot inserts. The total allowed amount of the foot inserts is $234.19, resulting in a coinsurance 
amount of $46.84. 
 
You have been asked to pay 20% coinsurance for a foot insert. Foot inserts 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 copayment 
for foot inserts on December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic drug assays (80197) provided on March 31, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached the supportive medical 
records to process as an appeal to have the claim reprocess for payment. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 therapeutic drug assays (80197) provided on 
March 31, 2022 by an out-of-network (OON) provider.