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 are appealing the denial of LTACH. 
The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be 
appropriately treated in the current 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 there is no documentation provided indicating medical necessity for admission to a LTACH. Our physician 
reviewer found the enrollee is receiving appropriate care at the present setting. 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
additional services are not medically necessary. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for a lower extremity wound. 30 treatments of hyperbaric 
oxygen therapy have been requested. The Plan has agreed to pre-approve 1 visit. The review has determined 
that additional treatments are not medically reasonable or necessary until results of the approved treatment has 
been considered. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hyperbaric oxygen therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the foot provided on February 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an x-ray of the foot. You say that the enrollee was seen for an x-ray of the foot. 
The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The Plan 
also says there is no referring provider involved in these services. The Plan also says that they did not authorize 
any services for this provider. 
 
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 x-ray of the foot provided on February 9, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics rendered on March 8, 2022. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the orthotics rendered on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 12, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the patient is a resident in a nursing home and has an 
authorization on file for all care at the facility. The Plan denied your request. The Plan says the provider is out-
of-network and authorization is required prior to an out-of-network service. 
 
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 12, 2022 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical refraction (92015) provided January 19, 2022. 
 
You asked the Plan to pay for the medical refraction. You say that you would like the refraction to be covered. 
The Plan denied your request. The Plan says this service is not covered under your benefits. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The medical eye refraction is not covered by Original Medicare. Therefore, we decided that the Plan does not 
have to pay for the medical refraction (92015) provided January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
January 20, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services 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 the services provided by an out-of-network provider on January 
20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for injection. You say that you received the injection in your 
doctors office so it should be covered. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $295 
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 $169.94 which is less than the standard $295 copayment for injection. The 
injection 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 an injection provided on February 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal (GI) tract imaging (91110). 
 
You asked the Plan to pre-approve a GI tract imaging. The Plan denied your request. The Plan says this request 
is not medically necessary because this testing is not covered to evaluate for decreased abdominal blood flow in 
the absence of GI blood loss. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must meet the covered indications listed 
in the Medicare rules section above. 
 
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 GI tract imaging. Our reviewer says 
that a GI tract imaging is not reasonable and necessary. Our physician reviewer found the review indicates that 
the enrollee is having abdominal pain after eating (though less than before the last vascular intervention). She 
does not have any evidence of GI bleeding. Our reviewer found that the enrollee's doctor states that the 
requested procedure is being asked for to examine for evidence of further decreased blood flow (ischemia) that 
would require vascular intervention. The review has determined that the enrollee does not have a condition 
which is indicated for coverage. Our physician reviewer also found that there are not any limitations as listed in 
the Local Coverage Determination (LCD) that would prevent coverage. 
 
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 GI tract imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a gastrointestinal (GI) tract imaging (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on January 27, 2022, and 
February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that the OON provider told you they were in-
network. The Plan denied your request. The Plan says the rendering provider is an OON provider and there was 
no approved authorization. Also, it was confirmed that the in-network provider referred the enrollee to another 
in-network provider, but the enrollee never responded. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on January 27, 
2022, and February 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 28, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are unhappy that the providers office stated to 
you that they were in-network, when in fact they are OON. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
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 February 28, 2022, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 10, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this service is not 
covered. 
 
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 does not cover eye refractions. 
 
We looked at the file and the Plan's rules. 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 eye refraction (92015) provided on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on February 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you would like to request reconsideration for 
payment. 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 laboratory testing provided on February 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual wheelchair rendered on December 13, 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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that manual wheelchair bases must be billed with the 
KX, GA, GY, or GZ modifier. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required 
modifiers. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the manual wheelchair rendered on 
December 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vascular access device provided on March 6, 2021, to April 
4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for vascular access device. 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 vascular access device provided on March 6, 
2021, to April 4, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the wrist hand finger orthosis provided on 
October 22, 2021. 
 
You asked the Plan to waive the deductible for the orthosis. You say that the Plan should be paying a portion of 
this bill. The Plan denied your request. The Plan says that the deductible must be met before they will pay 
anything. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
contract with the Plan says that there is $1,000 deductible for covered medical services.  
 
The item or service you asked the Plan to pay for falls within the benefit category covered medical services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 deductible for 
covered medical services. This cost sharing is a contractual obligation that has not yet been met. Therefore, we 
decided that the Plan does not have to waive the deductible for the wrist hand finger orthosis provided on 
October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the Medicare guidelines of IRF 
admission. The Plan denied your request. The Plan says the records do not show the enrollee needs to be seen 
by a rehabilitative doctor at least 3 times a week and they do not need an intensive team for their care. The 
enrollee can safely receive services in another setting like a skilled nursing facility, home health services, or 
outpatient therapy. 
 
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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. At the current functional level, the enrollee does not need intensive therapies consisting of at least 
3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. 
 
IRF admission is not medically necessary based lack of medical complexity and acute rehabilitation nursing 
needs. Documentation does not support the medical necessity for admission to an IRF. While the enrollee may 
benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely 
provided in a lower intensity and alternate setting such as in a skilled nursing facility or continued therapy at 
home. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the home delivered meals provided on February 11, 
2022. 
 You asked the Plan to pay more for the home delivered meals. You say that a shipment was missed and not 
delivered to you. The Plan denied your request. The Plan says at the time of purchase on 2/11/2022, you had a 
remaining balance of $2.42 on the OTC (over the counter) card for the quarter. The Plan also says that you 
were reimbursed the remaining balance of $2.42, the remaining balance of the request is denied because you 
exceeded the frequency limit on the OTC benefit for the quarter. 
 
The Plan must follow Medicare rules. Medicare rules say that home delivery of meals may be offered as a 
supplemental benefit. 
 
We looked at the file and Medicare rules. The record shows that your $70 allowance for personal care and 
grocery items was exhausted on February 11, 2022. Based on this information, we decided that Medicare rules 
for coverage of the home delivered meals have not been met. Therefore, we decided that the Plan does not have 
to pay more for the home delivered meals provided on February 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on December 
29, 2021. 
 
You asked the Plan to pay for the hospital care. You say that the medically necessary services were rendered to 
the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 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 the subsequent hospital care (99232) provided on December 
29, 2021.