Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 an office visit 
provided on January 5, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the computed tomography scan 
should be approved for the enrollee because they have chronic obstructive pulmonary disease (COPD) and 
sleep apnea. You also say that the enrollee wheezes and coughs a lot. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 
 We reviewed the file and the Medicare rules. We find that the enrollee is not between the ages of 55 and 77 
years old, and the enrollee quit smoking more than 15 years ago. Therefore, we decided that the Plan does not 
have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable 
and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 is a 71-year-old male with a history of laryngeal cancer, 
hypertension, congestive heart failure peripheral arterial disease, chronic kidney disease, and iron deficiency 
anemia. Surgery is currently scheduled for August 18th, 2022. He was admitted to the hospital on July 21st, 
2022, and transferred to the LTACH on July 29th, 2022. He is on a T piece with low flow oxygen. In this case, 
there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee does 
not require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous durable medical equipment, adjustable bed, 
mattress, mattress protector and cooling pillow (E1399) and sales tax (S9999) purchased October 28, 2021. 
 
You asked the Plan to pay for the adjustable bed, mattress, mattress protector and cooling pillow. You say that 
you are appealing for reimbursement of a bed you had to buy for your chronic back pain. You are being treated 
with pain management, chiropractor treatments, water aerobics and an adjustable bed. All of this is needed to 
avoid surgery. The Plan denied your request. The Plan says if you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for miscellaneous durable medical 
equipment, adjustable bed, mattress, mattress protector and cooling pillow (E1399) and sales tax (S9999) 
purchased October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench. 
 
You asked the Plan to pre-approve a transfer bench. You say that this device is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this is not a covered benefit under Medicare or the Plan. 
 
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 pre-approve a transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that this is medically reasonable 
and necessary for the enrollee's condition. 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 the enrollee does not 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 sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
(72148). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that in this case, the record indicates that the 
enrollee has a history of peripheral neuropathy likely due to alcohol use. The record does not indicate that there 
has been any acute change. The record does not include a comprehensive neurologic examination. The record 
indicates that a repeat Electromyography (EMG) test will be requested. The requested service is not medically 
necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The 
elements of the coverage criteria are not satisfied. The requested service cannot be 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (21936) provided on December 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this procedure is 
included in the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgical procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
   
We looked at the file and Medicare rules. The requested services are included in the global surgical payment 
for the procedure (21931) performed on November 10, 2021. Procedure code 21931 has a global surgery period 
of 90 days. Separate payment cannot be made for code 21936 in this case. 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 pay for the services (21936) provided on December 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from December 2, 2020, to 
December 4, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that an inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from December 2, 2020, to December 4, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for CT scan provided on December 10, 2021. 
 
You asked the Plan to waive the deductible for CT scan. You say that this charge should be covered. The Plan 
denied your request. The Plan says the deductible applied is correct. 
 
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 $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
CT scan was received on December 10, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for CT scan provided on December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venclexta. 
 
You asked the Plan to pre-approve Venclexta. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Venclexta.  
 
Benefits for Venclexta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued rental of Bi-pap device and supplies (E0470, 
A7035, A7036, A4604, A4604, A7030, A7039, A7028, A7029, A7031, A7032, A7033, A7038, E0562). 
 
You asked the Plan to pre-approve the Bi-pap device and supplies. You say that please see all attached 
documents for why this enrollee is in need of CPAP to be continued on rental for the next 10 months. The Plan 
denied your request. The Plan says medical necessity for the request was not substantiated because the 
Medicare criteria was not met. 
 
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 Bi-pap device and supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found BiPAP is considered not medically necessary because the enrollee has been 
unable to use the device enough for effectiveness. The most recent clinical visit was 1/13/2022, at which time 
compliance issues were addressed by decreasing BiPAP pressures. Usage documentation covering 12/10/21 - 
3/9/2022 does not meet criteria, with only 17% of days with at least 4 hrs./day. Looking at the usage graph, 
there was even less usage after the pressure change, with no days with at least 4 hours use after 1/15/2022. The 
denial is upheld. 
 
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 Bi-pap device and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued rental of Bi-pap device and supplies (E0470, A7035, A7036, 
A4604, A4604, A7030, A7039, A7028, A7029, A7031, A7032, A7033, A7038, E0562).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee requires physical therapy and 
occupational therapy. You also say that the enrollee requires around the clock supervision at this time, which 
cannot be provided at home. The Plan denied your request. The Plan says according to the information they 
reviewed on the appeal, the requested service is not medically necessary. 
 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 
this does not meet criteria. 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 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee will benefit from continuing 
physical therapy to address deficits in lumbar range of motion, to reduce low back pain, decrease risk of falls 
and to decrease lumbar disability. The Plan denied your request. The Plan says the enrollee has shown good 
response to prescribed modalities and is able to continue a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has had prior therapy and can transition to an 
independent exercise program and does not require the ongoing skills of a professional therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14-day reader device. 
 
You asked the Plan to pre-approve Freestyle Libre 14-day reader device. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been satisfied. 
 
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 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 Freestyle Libre 14-day reader device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-day reader 
device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for LTACH 
services. The Plan denied your request. The Plan says the enrollee is medically unstable for transfer. The 
enrollee has not completed the acute hospital course. The care needs of the enrollee can be safely managed in 
the current acute care setting. The enrollee does not have clinical conditions that cannot be appropriately 
treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. 
 
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 appears to currently be unstable and requires additional acute care 
hospital services that can safely be completed at the current facility until more stable. The enrollee does not 
require services at the LTACH that are not already available at the current facility. 
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary at this time as the enrollee is too unstable for 
transfer and as it would not be clinically advantageous. Completion of treatment 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 the LTACH services.