Persius/hicric huggingface dataset:
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital from a skilled nursing facility with nosocomial pneumonia and abdominal pain. He developed respiratory failure and is still on a ventilator and requiring acute care services. He continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. LTACH services are not reasonable or medically necessary.

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 pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311), a hand or chin control interface (E2373), an electronic egg switch and 
graphical display (K0108x2), and a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection, a hand or 
chin control interface, an electronic egg switch and graphical display, and a power seat elevation feature. You 
say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan 
says medical necessity rules for coverage of the requested items have not been 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 an expandable controller with harness 
and electronic connection, an electronic egg switch, and a graphical display. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that that the requested electrical accessories are not medically necessary as the enrollee does have use of 
the upper extremity and can operate and control the power options using the switches that are included in the 
basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection, an electronic 
egg switch, and a graphical display have not been met. A hand or chin control interface can only be used with 
an expandable controller which in this case is noncovered. Therefore, a hand or chin control interface is not 
covered. A power seat elevation feature is not primarily medical in nature. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection 
(E2311), a hand or chin control interface (E2373), an electronic egg switch and graphical display (K0108x2), 
and a power seat elevation feature (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0427) provided from November 14, 2021, to January 16, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. 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 $200 
copayment for Ambulance services.  
 
 You have been asked to pay a $600 copayment for 3 ambulance transportation services ($200 x 3 = $600). 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 transportation services (A0425, A0427) provided 
from November 14, 2021, to January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 18, 
2021 and October 25, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that the two visits consisted of 
examining a scrape on each leg, cleaning and then rewrapping the dressings.  You say this was not minor 
surgery. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.   
You have been asked to pay a total of $500 ($250 x 2 visits = $500). Outpatient surgery falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery 
provided on October 18, 2021 and October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64494) provided on January 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has 
been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 (64494) 
provided on January 27, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on September 
24, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this should be sent to Original Medicare for processing. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided to the enrollee on September 
24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0427) provided on September 10, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $150 copayment for Ambulance services.  
 
 
  The enrollee has been asked to pay a $150 copayment for the ambulance transportation services. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for ambulance transportation services (A0425, A0427) provided on 
September 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail ibandronate injection (Boniva IV) or 
zoledronic acid injection (Reclast); OR has tried one oral bisphosphonate or oral bisphosphonate-containing 
product and or documentation of inability to tolerate these medications or a medical condition that 
contraindicates these medications. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the case file does not contain 
documentation of a trial of ibandronate injection (Boniva IV) or zoledronic acid injection (Reclast); OR one 
oral bisphosphonate or oral bisphosphonate-containing product. The documentation does not support that the 
plan's required drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and electrocardiogram (ECG) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and ECG to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria 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 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 
an office visit and electrocardiogram (ECG) 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 pay for the home health services provided on September 22, 2021, 
by an OON provider. 
 
You asked the Plan to pay for the home health services. You say that you were told the enrollee was covered 
under Medicare and originally submitted the claim to Medicare. You did not know an authorization was needed 
to provide the service to the enrollee. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 home health services provided on September 
22, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 29, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you don't feel you should 
have to pay for the mileage and the copayment. The Plan denied your request. The Plan says the copayment 
was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way Medicare-covered trip both in-network and out-of-network. 
 
You have been asked to pay $250 for the ambulance services. Ambulance services fall 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 the ambulance services 
provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for a home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found a home ventilator is 
not medically necessary. This enrollee was admitted with acute respiratory failure with hypercapnia, likely due 
to a combination of obesity hypoventilation syndrome, congest heart failure (CHF), and severe anemia. 
Chronic obstructive pulmonary disease (COPD) is mentioned in the record but there are no pulmonary function tests to support the diagnosis. There is no arterial blood gas (ABG) done when stable as an outpatient to 
confirm chronic CO2 retention. The enrollee may benefit from bipap, with or without AVAPS, during sleep. 
Medicare does not pay for a home ventilator when used as bipap. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for negative pressure wound therapy (97605) provided on 
December 16, 2021. 
 
You asked the Plan to pay for negative pressure wound therapy. You say that the claim at issue has been 
underpaid by the Plan. The Plan denied your request. The Plan says rules for payment have not been met. 
 
 
 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 negative pressure wound therapy 
(97605) provided on December 16, 2021. have been met. Specifically, no medical records were provided in this 
case to support the separate reporting of the code at issue. Therefore, we decided that the Plan does not have to 
pay for negative pressure wound therapy (97605) provided on December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan of the 
chest provided on January 27, 2022. 
 
You asked the Plan to reduce the copayment for a CT scan. You say that you always pay your copayment when 
your insurance also paid. You also say that your insurance paid nothing towards this claim. 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 $185 
copayment for radiological diagnostic services, including CT scans.  
 
The CT scan is a covered service that has cost sharing. If the allowed amount is less than the cost sharing 
amount found in the EOC, you are responsible for the full allowed amount. You have been asked to pay the allowed amount of $155.19, which is less than the $185 copayment for a CT scan. A CT scan 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 reduce the copayment for a computed tomography (CT) scan of the chest provided on January 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bio Te compounded bioidentical hormone replacement 
therapy (11980) provided on July 1, 2020. 
 
You asked the Plan to pay for the hormone replacement therapy. You say that you would like reconsideration 
because this is a Food and Drug Administration approved and medically necessary service. The Plan denied 
your request. The Plan says experimental and non-proven services that are not accepted standard of care are not 
covered by Medicare or the Plan. 
 
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 Bio Te compounded bioidentical 
hormone replacement therapy (11980) provided on July 1, 2020. have been met. Specifically, the 
documentation submitted does not include any medical records. We are unable to determine if the services at 
issue are medically reasonable and necessary. Therefore, we decided that the Plan does not have to pay for Bio 
Te compounded bioidentical hormone replacement therapy (11980) provided on July 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says your needs can be met at a lower level of care such as in a long-term care facility, 
or at home with home health care services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the patient requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. There is no 
documentation that daily skilled services are required, as you are walking household distances with a rolling 
walker with supervision. You are at supervision level for transfers. The provided records do not document a 
significant decline in your functional status to necessitate daily inpatient skilled therapy services. You do not 
require the services on an inpatient basis, only in a skilled nursing facility setting. The records do not document 
that services in the assisted living facility with home health care or in a long-term care facility on a part time 
basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).