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

 
We decided that the Plan does not have to pay for the eye surgeries provided on August 02, 2022, to August 25, 
2022. 
 
You asked the Plan to pay for the eye surgeries. You say that you were informed that you would only have a 
copayment for each procedure. 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 eye surgeries 
provided on August 02, 2022, to August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for tissue regeneration (D4265/D4277/D4287) provided on January 12, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for this. The Plan denied 
your request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for tissue regeneration (D4265/D4277/D4287) 
provided on January 12, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound care visit provided on November 22, 2022. 
 
You asked the Plan to pay for a wound care visit. You say that the records attached support the services 
provided. 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 wound care visit 
provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 24, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the records attached support the 
services provided. 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 subsequent nursing 
facility care provided on August 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous image-guided lumbar decompression 
(PILD) (27279, 0775T, 0275T). 
 
You asked the Plan to pre-approve the PILD. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not 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 the PILD. Our physician reviewer 
found the PILD procedure is experimental. More research is 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 PILD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the percutaneous image-guided lumbar decompression (PILD) (27279, 0775T, 0275T).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
May 30, 2022. 
 You asked the Plan to pay for the subsequent nursing facility care services.. You say that the services were 
rendered in good faith and your doctor is seeking reimbursement for payment at the maximum allowed. 
The Plan denied your request. The Plan says services should be billed under Original Medicare. 
 
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 nursing facility care services provided on May 
30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging, 
tomography (SPECT) provided on January 04, 2023. 
 
You asked the Plan to waive the copayment for a myocardial perfusion imaging, tomography (SPECT). You 
say that the copayment charged is a lot and you do not think you would qualify for help. 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 $200 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $200 copayment for a myocardial perfusion imaging, tomography (SPECT). 
This item/service falls within the outpatient diagnostic test 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 a myocardial perfusion imaging, tomography (SPECT) provided on January 04, 
2023.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 is unable to participate in intensive rehabilitation and the enrollee is at 
high risk of poor neurological recovery and not returning to community living. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has no daily skilled nursing needs and is not willing or able to participate 
in daily skilled therapy. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from September 9, 2022, to 
September 12, 2022. We decided that the Plan does not have to pay for inpatient hospital care provided on 
September 8, 2022.   
You asked the Plan to pay for inpatient hospital care provided from September 8, 2022, through September 12, 
2022. You say that the stay was medically necessary. The Plan says that the stay was not medically necessary. 
 
We decided that the Plan has to pay for inpatient hospital care provided from September 9, 2022, to 
September 12, 2022.  
 
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 inpatient hospital care. Our physician 
reviewer found as of September 9, 2022, the enrollee had new complications and was diagnosed with an acute 
stroke. The inpatient admission from September 9, 2022, to September 12, 2022, was medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have been met. Therefore, we decided that the Plan has to 
pay for inpatient hospital care provided from September 9, 2022, to September 12, 2022.  
 
We also decided that the Plan does not have to pay for inpatient hospital care provided on September 8, 
2022. 
 
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 inpatient hospital care provided on 
September 8, 2022. Our physician reviewer found the documentation indicates the enrollee was stable with an 
incidental diagnosis of pulmonary embolism on September 8, 2022. Inpatient admission was not required on 
September 8, 2022, as the enrollee could be treated at an observational 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 inpatient hospital care provided on September 8, 2022, have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on September 8, 
2022. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on October 21, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest home 
visit provided on October 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on May 5, 2022, to May 
12, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the services were medically necessary. The 
Plan denied your request. The Plan says these services are not covered by the plan under Part B. 
 
 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 pay for self-administered drugs provided 
on May 5, 2022, to May 12, 2022.  
 
Benefits for self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 02, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 services 
provided on February 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on April 19, 
2022, to May 17, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the records attached support 
the services provided. 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 subsequent nursing 
facility care visit provided on April 19, 2022, to May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pre-fabricated knee orthosis L1845. 
 
You asked the Plan to pre-approve the orthosis. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the record does not show recent injury/surgery to the knee, or knee 
instability. 
 
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 orthosis. Our physician reviewer 
found meniscal tears cause pain, locking and clicking but do not necessarily cause instability. The criteria are 
not met because of absent instability or recent surgery or injury per LCD 33318. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the pre-fabricated knee orthosis L1845.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy (J9228). 
 
You asked the Plan to pre-approve the drug. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested use of this drug/regimen is not reasonable 
and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our physician reviewer found 
the requested use of Yervoy is not FDA-approved for the enrollees diagnosis. Treatment is for first line and in 
combination with nivolumab. This enrollee has prior progression on immunotherapy (pembrolizumab) and has received several prior lines of therapy in the metastatic setting. The use is not supported by one of the major 
drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-
approved medical journal. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Yervoy (J9228).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have any parental medication; complex wound care or nutrition 
given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical 
problems. The enrollee's physical function is at or near the enrollee's baseline and she can receive services at a 
lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on December 12, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you already 
paid a $40 copayment and do not understand why you are being charged a hospital building facility fee. 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 $135 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $135 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $134.05, which is less than the standard $135 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets specific criteria. 
 
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 powered pressure-reducing air 
mattress. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not currently have a condition such as multiple ulcers or stage 3 or ulcers or recent surgery which 
fulfill criteria for medical necessity per Medicare. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).