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

 
We decided that the Plan does not have to pay for debridement provided on October 27, 2022. 
 
You asked the Plan to pay for debridement. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement provided 
on October 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an LTACH care. 
 
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 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 the 
enrollee is currently receiving care. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee was on a Bipap with Azatas 
setting that provides a title volume and back rate and the enrollee was still hypercapnic. Back rate is not 
lowering her Co2 level to normal ranges. The enrollee needs to go home with a ventilator. The Plan denied 
your request. The Plan says use of a portable ventilator to deliver ventilatory support via settings that could be 
similarly provided by a Bi-level w/ assist with ST or AVAPS settings, is inconsistent with the LCD. The 
requested device would be used in a Bi-level w/ assist mode that could be provided with a Bi-level w/ assist 
device with ST, or AVAPS, added to assure adequate tidal volumes. 
 
 
 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 service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. 
Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. As 
stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 you have been there before and believe that their 
intensive therapy will help you to return to your prior level of function. The Plan denied your request. The Plan 
says records do not show that you have complex medical, and therapy needs or that you need an intensive 
therapy program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 this is the most appropriate level of care 
for the enrollee to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the 
enrollee's 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 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 health plan has approved ongoing care 
in the current acute care 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 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: Partially Favorable

 
We decided that the Plan has to lower the cost share for emergency room visit. We decided that the Plan does 
not have to waive the cost share for emergency room visit.  
 
You asked the Plan to waive the cost share for emergency room visit and outpatient hospital services provided 
on September 28, 2022. You say that you disagree with the cost share. 
 
The total amount you are being asked to pay is $863.06 towards your $1,000 deductible. The total amount you 
are being asked to pay is $953.06 ($863.06 + $90 = $953.06). 
 We decided that the Plan has to lower the cost share for emergency room visit.  
The Plan follows Medicare rules. 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 enrollees must pay a $119 copayment for 
emergency room services. 
 
Based on the Plan contract, however, you cannot be asked to pay more than a $90 copayment for emergency 
room services. 
 
 Therefore, we decided that the Plan has to lower the cost share for emergency room visit.  
 
We also decided that the Plan does not have to waive the cost share for emergency room visit. 
 
 Therefore, we decided that the Plan does not have to waive the cost share for emergency room visit. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on July 18, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you thought the services were covered 
by your Plan. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the psychotherapy 
services provided on July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on August 30, 2022. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory drug testing 
provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
October 19, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the lab charge should be 
included in the annual physical. The Plan denied your request. The Plan says this cost sharing was charged 
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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service 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 the laboratory services provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the neurology specialist office visit 
provided on August 22, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not satisfied 
with the services received. The Plan denied your request. The Plan says this cost sharing was charged 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 $50 
copayment for in-network specialist office visits.  
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner 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 neurology specialist office visit provided on August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stays from August 
17, 2022, to August 20, 2022, and from September 22, 2022, to September 26, 2022. 
 
You asked the Plan to waive the copayments for the inpatient hospital stays. You say that you cannot afford to 
make these copayments. The Plan denied your request. The Plan says this cost sharing was charged 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 $275 
copayment per day for days 1-7 of each inpatient hospital stay.  You have been asked to pay a $275 copayment per day for days 1-3 of the inpatient hospital stay from August 
17, 2022, to August 20, 2022. You have been asked to pay a total of $825 for this stay ($275 copayment per 
day x 3 days = $825). You have also been asked to pay a $275 per day for days 1-4 of the inpatient hospital 
stay provided from September 22, 2022, to September 26, 2022. You have been asked to pay a total of $1,100 
for this stay ($275 copayment per day x 4 days = $1,100). These item/service 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 waive the copayments for the inpatient hospital stays from 
August 17, 2022, to August 20, 2022, and from September 22, 2022, to September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided on October 20, 2022. 
 
You asked the Plan to pay for a colonoscopy. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a colonoscopy provided 
on October 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 20, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not 
submitted from the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain a physician order or 
medical records showing the ordering physicians intent that the testing be performed. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on July 20, 2022.
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 this is the best treatment plan for enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
inpatient rehabilitation facility. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 wound care services provided on December 12, 2022. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care services 
provided on December 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic ultrasound provided on June 24, 2022. 
 
You asked the Plan to pay for a diagnostic ultrasound. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a diagnostic ultrasound 
provided on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is diagnosed with obesity 
hypoventilation syndrome. Unfortunately, this was discovered when she was hospitalized for respiratory failure 
with critical PaCO2 retention in the 70s. Her alveolar hypoventilation has clearly been occurring for some time 
now and she needs non-invasive ventilatory (NIV) support at home to maintain normal ventilation and prevent 
future respiratory failure from occurring again. The Plan denied your request. The Plan says the doctor has 
prescribed a ventilator to help the enrollee's breathing at various times of the day because of lung disease. 
Medicare does not cover ventilators used in this way. 
 
 
 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 service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
obesity hypoventilation syndrome with cor pulmonale and a history of pulmonary emboli. Provided records 
document that the home ventilator is being requested for use in targeted tidal volume, volume assured pressure 
support (TTV-VAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with average 
volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).