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 two independent physical therapists and the 
neurosurgeon have all said that inpatient physical therapy is medically necessary and required for your 
rehabilitation after lumbar spinal fusion surgery. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for approval of IRF care. The Plan say that the enrollee can safely receive the 
services needed in other settings. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has a past medical history of spinal stenosis and has weakness and trouble walking. The enrollee's medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and infectious agent antigen detection 
by immunoassay technique (87428) provided on November 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit (99203) and infectious agent antigen detection by immunoassay 
technique. You say that the services should be covered. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services provided out-of-network. 
 
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 the office visit 
(99203) and infectious agent antigen detection by immunoassay technique (87428) provided on November 27, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on February 10, 
2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $233 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $233 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time the office visit was received on February 10, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible for an office visit provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this equipment is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 15, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Plan, this provider has not submitted any clinical records to support the medical 
necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on November 15, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 15, 2021.
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 the enrollee is stable for transfer to the 
LTACH where care can be given with the appropriate medical oversite of his clinical condition. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
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 unstable and requires short-term additional acute care 
services that can safely be administered at the current facility until more stable and when a lower level of care 
is more appropriate. The enrollee does not require services at the LTACH that are not already available at the 
current facility. Transfer to LTACH is not medically necessary as the enrollee is unstable and as it would not 
be clinically advantageous. Completion of care at the current facility is recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on December 17, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Domiciliary services provided on December 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory work to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the laboratory work. You say that the services were medically necessary. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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. We found no exception that would 
require the Plan to pre-approve these items/services. The records provided for review do not show that the 
services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve 
laboratory work to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the group 3 power wheelchair with power function. We decided 
that the Plan does not have to pre-approve the upgraded electronics.  
 
You asked the Plan to pre-approve the power wheelchair and upgraded electronics. You say that you are 
requesting reconsideration of the medical necessity of all the components of this K0861 required by the 
enrollee to meet her medical, functional and mobility needs throughout the day in her home. The Plan says that 
the enrollee does not meet the criteria for the requested wheelchair and the upgraded electronics are not 
medically necessary. 
 
We decided that the Plan has to pre-approve a group 3 power wheelchair with single power option and 
does not have to pre-approve the upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve the upgraded electronics, expandable 
controller, E2377, harness for upgrade to expandable controller, E2313 and electronic connection 
between wheelchair controller and two or more power seating system motors, E2313. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the power wheelchair and upgraded 
electronics. Our reviewer says that the enrollee meets the criteria for the requested wheelchair, but the upgraded 
electronics are not medically necessary. Our physician reviewer found a group 3 power wheelchair with power tilt is reasonable and necessary as spina bifida is a qualifying diagnosis with documented mobility impairments. 
It is specifically documented that the enrollee is not effectively able to weight shift thus power tilt is reasonable 
and necessary. However, there is no documentation to support the upgraded electronics (expandable controller, 
(E2377) harness for upgrade to expandable controller (E2313) and electronic connection between wheelchair 
controller and two or more power seating system motors (E2313) and with the seating evaluation there was no 
reason listed.  
 
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 power wheelchair and upgraded electronics have been met. Therefore, we 
decided that the Plan has to pre-approve a group 3 power wheelchair with single power option and does not 
have to pre-approve the upgraded electronics.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy with biopsy (45380) provided on April 6, 
2021. 
 
You asked the Plan to pay for the colonoscopy services. You say that this service is separately payable. The 
Plan denied your request. The Plan says the endoscopy services were paid appropriately according to Medicare 
rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that if Field 21 contains an indicator of 3, and multiple endoscopies are billed, the special rules 
for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the 
difference between the next highest and the base endoscopy. 
 We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, the codes at issue on this claim have an 
indicator of 3 and the same base endoscopy code. The record clearly indicates that the Plan paid the full value 
of the highest valued endoscopy, plus the difference between the next highest and base endoscopy. Therefore, 
we decided that the Plan does not have to pay for the colonoscopy with biopsy (45380) provided on April 6, 
2021.
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 LTACH services. You say that you are requesting LTACH services because 
its expected the enrollee will require anther 3-4 weeks to continue weaning off the ventilator and to transition 
from his acute illness. The Plan denied your request. The Plan says the enrollee remains clinically unstable for 
transfer and their care can be provided in the current inpatient hospital. 
 
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 does not require services at the LTACH that are not already 
available at the current facility. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for the ECG. You say that the ECG was part of your annual 
wellness visit and you should not have a copayment. 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 no 
coinsurance, copayment, or deductible for the annual wellness visit. 
 
Your contract with the Plan also clearly says that you must pay a $5 copayment for diagnostic procedures 
performed in a PCP's office, including ECG's. The file shows that you were not charged for the wellness visit. However, the ECG is an additional services 
that goes beyond the scope of a wellness visit. Therefore, you have been asked to pay a $5 copayment for the 
ECG. The ECG falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 an electrocardiogram (ECG) provided on 
February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on October 4, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you would have seen a different provider 
if you knew the provider would not accept your insurance. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there is no referral from an in-network provider or an approved 
authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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 a specialist office visit provided on October 4, 
2021, by an OON provider.   
Your complaint about your experience with this 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an inpatient hospital stay provided from 
October 15, 2021, to October 27, 2021. 
 
You asked the Plan to lower the copayment for the inpatient hospital stay. You say that your copayment should 
be lower than what was charged. The Plan denied your request. The Plan says the proper copayment 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 $225 
copayment for In-Network per day for days 1-7 per admission for Medicare-covered inpatient hospital stays. 
From October 15, 2021, to October 27, 2021, the total length of the inpatient hospital stay was 13 days. Since 
the copayment is applied up to the first 7 days the total copayment amount charged was $1,575 ($225 
copayment per day x 7 days). 
 
You have been asked to pay a $1,575 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital 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 lower the copayment for an inpatient hospital stay provided from October 15, 2021, 
to October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy procedure (52310) 
provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that the services 
should be covered as you disagree with the charges. 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 $275 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $275 copayment for the cystourethroscopy procedure. Cystourethroscopy 
procedures fall 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 a 
cystourethroscopy procedure (52310) provided on February 7, 2022.