Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs are too complex for 
a lower level of care. The Plan denied your request. The Plan says the enrollee is unstable for transfer. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with seizure activity, acute respiratory 
failure, viral pneumonia. Recent notes describe the enrollee responding to treatment and now tolerating trach 
collar with high flow oxygen. She is still being treated and monitored for worsening chest x-ray findings.  
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on December 6, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told there was no charge. 
The Plan denied your request. The Plan says the copayment amount charged 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 a $285 
copayment for advanced imaging services.  
 
 
 
 You have been asked to $170.44, which is less than the Plan's EOC documented $285 copayment for the CT 
scan. CT scans fall within the Outpatient Hospital 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 computed tomography (CT) scan provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare rules. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electrical hospital bed for the enrollee. 
 
You asked the Plan to pre-approve a semi-electrical hospital bed. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that the patient's history does not reflect a diagnosis 
requiring positioning not feasible without a semi-electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electrical hospital bed. Our 
reviewer says that a semi-electrical hospital bed is not medically reasonable and necessary. Documentation 
doesnt support that the member has a condition that requires frequent positioning of the bed and mattress to 
alleviate pain, promote good body alignment, prevent contractures or avoid respiratory infections in a way that 
an ordinary bed is not able to. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for a semi-electrical hospital bed. 
 
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 semi-electrical hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electrical hospital bed for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 12, 2021, to October 15, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would like the Plan 
to pay for one additional day. You also say you did not have the support person traveling with you for 
assistance after having surgery. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $395 
copayment per day for days 1-4 of an out of network inpatient hospital stay. There is no charge after day 4. 
 You have been asked to pay a $395 copayment for an inpatient hospital stay. There is no charge after day 4. An 
inpatient hospital stay 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 copayment for an inpatient hospital stay provided from October 12, 2021, to October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
October 10, 2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel you 
should not have been discharged from your previous stay. You say that this should be considered one stay. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $225 per 
day for days 1-6 and $0 per day for additional days for each hospital admission.  
 
The file shows that you were readmitted to the hospital from October 10, 2021, to October 14, 2021. Since this is a new admission, you have been asked to pay $225 per day for the first 4 days of inpatient hospital services. 
The total for your stay is $900 ($225 copayment x 4 days = $900). The inpatient hospital services fall 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 copayment for inpatient 
hospital services provided from October 10, 2021, to October 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
November 17, 2021, to November 19, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that this was an emergency, 
and the charges should be waived. The Plan denied your request. The Plan says the copayment amount charged 
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 a $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 
within the Emergency 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 copayment for emergency 
room services provided on November 17, 2021, to November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on the neck provided on  
June 18, 2021. 
 
You asked the Plan to pay for anesthesia for procedures on the neck. The Plan denied your request. The Plan 
says the medical records submitted do not meet urgent/emergent criteria. The services are available in network. 
The services were not prior 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for anesthesia for procedures on the neck provided on June 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new 
ostomy, new TFs). The enrollee does not have documented skilled therapy needs. The enrollee appears to be 
functioning at/near their baseline. Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on March 1, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the physical therapy. You say that a previous claim was partially paid for the 
same procedure code and same rendering provider. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. The Plan says the previous claim was 
partially covered due to an administrative error. 
  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 physical therapy provided on March 1, 2021, 
by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
2, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not agree with a $250 
copayment for ambulance services. You also say that you were picked in the ambulance from your doctor's 
office and transported across the parking lot to the hospital. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $250 
copayment for ground ambulance transport.  
 
The medical record shows you were transported by ambulance to the hospital on November 2, 2021. You have 
been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the Ambulance 
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 ambulance services 
provided on November 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you can hardly walk. The Plan denied your 
request. The Plan says you do not need daily skilled nursing or therapy care. 
 
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 services. Our physician reviewer 
found that you were admitted to an acute hospital for a planned L4-L5 laminectomy and fusion. You have 
stabilized medically and is ready for discharge from the hospital. You do not require skilled nursing or skilled 
therapy services on a daily basis. Although further rehab services would be appropriate to improve function, as 
a practical matter, the intermittent skilled services can be provided at a lower 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311) for a power 
wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that this features is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 expandable controller. Our reviewer 
says that the expandable controller is not medically necessary.  Our physician reviewer found the requested accessories are not medically necessary as the enrollee has use of 
her hands and can operate and control the power options using the switches that are included in the basic 
wheelchair. 
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2311) for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory service (CPT code 81539). 
 
You asked the Plan to pre-approve the laboratory service. You say that the service is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met.  
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 laboratory service. Our physician 
reviewer found this service is denied as you already have a diagnosis of prostate cancer. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the laboratory service (CPT code 81539).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit on October 12, 2021, by an OON provider. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and 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 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 office visit on October 12, 2021, by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on November 17, 2021, from an 
out-of-network provider. You asked the Plan to pay for eyeglasses. You say that you were referred to this provider by the Plan. The Plan 
denied your request. The Plan says this provider is not part of the specified supplemental routine vision vendor 
network. Services obtained from providers outside of this network are 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 covers these services when they are obtained from a provider within the specified routine 
vision vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified routine 
vision vendor network. Based on this information, we decided that the Plan's rules for coverage of eyeglasses 
have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on 
November 17, 2021, from an out-of-network provider.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the physicians services. 
 
You asked the Plan to waive the deductible for the physicians service. The Plan denied your request. The Plan 
says the claim processed correctly. Your deductible of $227.31 was applied to your 2021 plan year deductible 
of $1000.00. 
 
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 
$1000.00 deductible for medical services.  
 
You have been asked to pay a deductible of $227.31 for the physicians services. The physicians services falls 
within the what is your plan deductible 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 deductible 
for the physicians services.