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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving 
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are 
not available at the acute care hospital where he 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 service are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee.  
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 out of network physician services provided to the enrollee 
from February 4, 2021 to March 3, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician services provided to the 
enrollee from February 4, 2021 to March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on June 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was 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 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent.  Therefore, we decided that the Plan does not have to pay for the drug testing provided on June 18, 2021, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve angioplasty and stent placement. 
 
You asked the Plan to pre-approve angioplasty and stent placement. You say that the request for angioplasty 
and stent placement is medically necessary. The Plan denied your request. The Plan says that the request for 
angioplasty and stent placement is not medically necessary. 
 
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 angioplasty and stent placement. Our 
reviewer says that the request for angioplasty and stent placement is medically necessary. Our physician 
reviewer found the enrollee has severe life-limiting claudication with severe multi-vessel thrombotic occlusions 
of lower extremity vessels which is most severe in the symptomatic right leg. She has been referred for PTA 
and stenting to improve ischemic symptoms. Given the extent of the multi-vessel vascular disease and the 
multiple thrombotic occlusions, and in the setting of severe life limiting symptomatic disease, an attempt at 
intervention and revascularization of the ischemic limb would likely provide the best opportunity for success in 
improving the claudication symptoms in lieu of conservative therapy in this situation. The planned angioplasty 
and stenting would therefore meet the applicable medical reasonableness and necessity criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of angioplasty and stent placement have been met. Therefore, we decided that the 
Plan has to pre-approve angioplasty and stent placement.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xtandi for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Xtandi for the enrollee.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the services can be received in different settings, for example, home with home 
health, in residential care, or home with close follow-up with the doctor. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested admission is medically reasonable and necessary. Our physician reviewer found that you qualify for 
SNF coverage. You do have documented skilled therapy needs. A brief period of skilled therapy is medically 
necessary to establish a maintenance program and/or prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a 
skilled nursing facility (SNF).  
 
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's left upper limb strength and function are therefore adequate for the 
enrollee to be able to control the power options using their own switches which are included in the allowance 
of these power options. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the enrollee meets 
Medicare criteria for coverage of the requested additional accessories (E2311, E2313, E2377). The records 
indicate the enrollee has 3+/5 left hand and wrist strength and no other reported left upper extremity limitations 
(such as contractures, fisting, tremors, weak grasp, poor dexterity, non-functional hand movements or 
paralysis) thus indicating adequate strength and function to control the wheelchair's power options with their 
own switches.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 1, 2021, to February 3, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be 
covered. The Plan denied your request. The Plan says the copayment applied correctly based on the services 
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 $345 
copayment for Inpatient hospital care.  
 You have been asked to pay a total copayment of $690 for 3 days of inpatient hospital care, which is less than 
$345 per day. 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 inpatient hospital care provided from 
February 1, 2021, to February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 wheelchair with multiple power options 
(power tilt and recline). 
 You asked the Plan to pre-approve a group 3 wheelchair with multiple power options (power tilt and recline). 
You say that the requested group 3 power wheelchair with multiple power options (power tilt and recline) are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
group 3 wheelchair with multiple power options (power tilt and recline). 
 
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 a group 3 wheelchair with multiple 
power options (power tilt and recline). Our reviewer says that the enrollee does not meet criteria for a group 3 
wheelchair with multiple power options (power tilt and recline). Our physician reviewer found based on the 
medical records provided there is no documentation that the enrollee meets all of the criteria for the requested 
group 3 power wheelchair with multiple power options (power tilt and recline). Although the enrollee does 
have a mobility limitation that impairs her ability to safely participate in activities of daily living and she may 
qualify for another type power wheelchair, the records from her providers (other than the vendor) do not 
document that she is at high risk for development of a pressure ulcer, that she utilizes intermittent 
catheterization for bladder management or the power seating system is needed to manage increased tone or 
spasticity. 
 
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 wheelchair with multiple power options (power tilt and recline) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 wheelchair with 
multiple power options (power tilt and recline).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided July 
20, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that you were referred to this provider to see if you 
were eligible for cataract surgery. The Plan denied your request. The Plan says eye refractions are only covered 
when rendered by a participating provider for routine vision care. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine exam by a participating routine 
vision provider. 
 
We looked at the file and the Plan's rules. In this case the eye refraction was performed as part of a medical 
vision check. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have 
not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state 
(92015) provided July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 14, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network physician services provided to the 
enrollee on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 88305, 88312, 87481) provided on May 
26, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for lab services (87798, 88305, 88312, 87481) provided on May 26, 
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on June 19, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were not hurt when the ambulance 
arrived. You say that you did not want to go to the hospital. You also say that you only had a skin tear. The 
Plan denied your request. The Plan says no transport was provided. The Plan says that since there was no 
transport, payment cannot be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 19, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on June 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for home health services (G0151, G0157) 
provided from March 5, 2021, to April 30, 2021. 
 
You asked the Plan to waive the copayment for home health services. You say that the services should be 
covered as there is no documentation to support a physical visit. The Plan denied your request. The Plan says 
the coinsurance applied correctly based on the services 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 20% 
coinsurance for Home Health Agency Care.  
 
You have been asked to pay a 20% coinsurance for home health services resulting in a total cost sharing of 
$822. The record shows that there are medical records supporting the visits in question. 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 home health services (G0151, G0157) provided from March 5, 2021, 
to April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 12, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior 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 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 out of network physician services provided to the 
enrollee on April 12, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after November 
15, 2021. 
 
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before November 15, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after November 15, 2021.  
 
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.