Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional reimbursement exceeding the $300 Wellness 
Bucks limit for nutritional counseling visits with a licensed nutrition counselor or registered dietitian. 
 
You asked the Plan to pre-approve additional reimbursement exceeding the $300 Wellness Bucks limit 
nutritional counseling visits with a licensed nutrition counselor or registered dietitian. You say that you 
struggle with an eating disorder. The Plan denied your request. The Plan says that the Plan will reimburse you 
up to $300 per year towards your cost for any of the programs and/or services listed under this benefit. You can 
submit as many reimbursement forms as necessary, but you will be responsible for all costs above $300 per 
year. While services can be combined, the total amount reimbursed by the Plan will not exceed $300 per year. 
We are unable to approve additional coverage outside of your covered Wellness Buck benefit. 
 
The Plan contract offers a supplemental Wellness Bucks benefit. The Plan says that the Plan offers you $300 
per year in Wellness Bucks. We looked at the file and the Plans rules. The Plans Wellness Bucks benefit does not provide coverage 
exceeding $300 reimbursement per year. Therefore, we decided that the Plan does not have to pre-approve 
additional reimbursement exceeding the $300 Wellness Bucks limit for nutritional counseling visits with a 
licensed nutrition counselor or registered dietitian.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The patient 
appears to be improving and should only require short-term additional acute care services that can safely be 
administered at the current facility. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for LTACH services. 
 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heel protector boots. 
 
You asked the Plan to pre-approve the boots. You say that this is medically necessary. The Plan denied your 
request. The Plan says no specific code or exact type of boots has been requested. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 There is no evidence of a face to face encounter with a physician who ordered this item. There is no detailed 
order present to verify exactly what kind of footwear is being requested here. Based on this information, we 
decided that Medicare rules for coverage of the boots have not been met. Therefore, we decided that the Plan 
does not have to pre-approve heel protector boots.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips beyond 
30 one-way rides to other care related locations (such as to the pharmacy or specialist appointments). 
 
You asked the Plan to provide coverage for additional routine transportation trips beyond 30 one-way rides. 
You say that you need additional trip rides to your dialysis treatment, which you stated you have 3 days per 
week, every week. The Plan denied your request. The Plan says your request for rides in addition to the 30 
one-way rides you are covered for exceeds the benefit limit. There are no exceptions that allow us to cover 
additional trips to locations other than your PCP. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation with unlimited rides to your PCPs office, and up to 30 one-way 
rides per year to other health care related locations (such as to the pharmacy or specialist appointments).   
 
We looked at your request, the records in the case file, and the rules. The file shows that the routine 
transportation benefit covers up to 30 one-way rides and there are no exceptions to cover additional trips other 
than to your PCP. Therefore, we decided that the Plan does not have to provide coverage for additional routine 
transportation trips beyond 30 one-way rides to other care related locations (such as to the pharmacy or 
specialist appointments).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography and computed 
tomography (PET/CT) scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this cannot be approved. 
 
  The Plan must follow Medicare rules. Medicare rules say that PET scans are not covered for prostate cancer. 
Therefore, we decided that the Plan does not have to pre-approve  a positron emission tomography and 
computed tomography (PET/CT) scan. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
positron emission tomography and computed tomography (PET/CT) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of one knee cartilage using an endoscope 
(29881). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that you do not meet guidelines for authorization for these services. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures (including physical therapy or any injection therapy.) There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Our physician reviewer found that your condition does not meet criteria for coverage of these 
services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve removal of one knee cartilage using an endoscope (29881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive to copayment for a cardiology specialist office visit provided 
on August 31, 2021. 
 
You asked the Plan to waive to copayment for a cardiology specialist office visit. You say that you were told 
that the insurance would cover all the claims related to COVID-19. You also say that you have been healthy 
before this virus happened. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. The Plan also says that COVID-19 related services are covered but that the copayment waiver 
period has already ended. 
 
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 $35 
copayment for a specialist office visit.  
 The records show the Plan will cover any relevant provider treatment if diagnosed with COVID-19. However, 
normal cost shares will apply for treatment of COVID-19 related symptoms. The record also shows that the 
copayment waiver for COVID-19 related claims ended on May 31, 2021. You received the office visit after the 
copayment waiver time ended. You have been asked to pay a $35 copayment for a cardiology specialist office 
visit. A cardiology specialist office visit falls within the Physician/Practitioner Services, Including Doctors 
Office Visits 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 to copayment for a cardiology specialist 
office visit provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on October 28, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that you had your eyes dilated by a machine because 
you had to drive. You also say you paid $20 at the time of service and this service should be covered. The Plan 
denied your request. The Plan says the service at issue is not a covered benefit. An eye refraction is only 
covered by the Plan when it is performed as part of a routine screening. 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 contract says that an eye refraction is only covered by the Plan when it is performed as part 
of a routine screening. 
 
We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, 
and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage 
of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphin. 
 
You asked the Plan to pre-approve Buprenorphin. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Buprenorphin.  
 
Benefits for Buprenorphin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for external mobile 
cardiovascular telemetry, duplex scan, and myocardial perfusion imaging for the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are cardiology 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 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 out-of-network referral for external mobile cardiovascular telemetry, duplex scan, and myocardial perfusion 
imaging for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation. 
 
You asked the Plan to pre-approve wheelchair van transportation. You say that you are in the process of getting 
a kidney transplant and you have no way of getting to medical appointments. The Plan denied your request. 
The Plan says wheelchair van transportation is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
psychotherapy services to be rendered by the out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support the need 
for the requested procedure. The Plan denied your request. The Plan says the requested service is considered 
experimental and investigational. The Plan says that the Intracept procedure is not generally accepted for the 
suggested use as reported in nationally recognized peer-reviewed medical literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services coded as Q0092, R0070, 72070 
and 72100 provided on May 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the portable x-ray services. You say that although you go into an inpatient 
setting, you are not required to have a pre-authorization because you are providing an outpatient service 
requested by the enrollee's physician for lack of mobility reasons. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 portable x-ray services coded as Q0092, 
R0070, 72070 and 72100 provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you called the Plan beforehand and were advised the provider was in-network. 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 $20 
copayment for Outpatient rehabilitation services.  
 
 
 
 
 You have been asked to pay a $20 copayment for physical therapy services. Physical therapy services fall 
within the Outpatient rehabilitation 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 physical therapy services provided on November 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided 
September 9, 2021 to October 3, 2021. 
 You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF 
services provided. The Plan denied your request. The Plan says medical necessity cannot be established for 
SNF level of coverage. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided September 9, 2021 to October 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 1, 2020, 
through September 30, 2020. 
 
You asked the Plan to pay for the home health services. You say that the claim was paid in full then taken back 
with no explanation. You say that the medical records are attached to be reviewed again. The Plan denied your 
request. The Plan says the care rendered was not based on the primary diagnosis. 
 
 
  The Plan follows Medicare rules. Medicare rules say that CMS finalized a new case-mix classification model, 
the Patient-Driven Groupings Model (PDGM), effective January 1, 2020. The PDGM relies more heavily on 
clinical characteristics, and other patient information to place home health periods of care into meaningful 
payment categories. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the home health services. Our reviewer says 
that the documentation does not support that the services provided were based on the primary diagnosis code. 
Our physician reviewer found that the focus of care was not on the primary diagnosis as the pressure ulcer was 
healed for this period of care. The provider completed 5 nursing visits and 8 physical therapy visits during the 
billing period September 2, 2020, through September 29, 2020, but the documentation fails to demonstrate why 
the skilled services were still needed. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided from September 1, 2020, through September 30, 2020.