Persius/hicric huggingface dataset:
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 SNF care is needed because you need assistance 
with your activities of daily living. The Plan denied your request. The Plan says SNF care is not medically 
necessary. 
 
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 you do not have documented skilled nursing needs and you do not have documented 
skilled therapy needs. You are likely at/near a new, lower level of function. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, 
custodial and intermittent, can, as a practical matter, 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 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 pre-approve a magnetic resonance imaging (MRI) scan of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve a lumbar MRI scan. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says medical-necessity rules for coverage of the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 a lumbar MRI scan. Our reviewer says 
that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found 
that you have back pain. The case record does not indicate the presence of any red- flag symptoms or abnormal 
neurological-examination findings. The record indicates that you have not been seen by a neurologist or 
neurosurgeon and the specialist requests the test before evaluation. 
 
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 lumbar MRI scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an MRI scan of the lumbar spine (72148).
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says SNF care is not medically necessary. 
 
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 no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition.  The enrollees care needs, custodial and intermittent, can, as a practical matter, 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003) with elevating leg 
rests (K0195). 
 You asked the Plan to pre-approve a lightweight wheelchair with elevating leg rests. You say that the requested 
items are a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the 
requested items have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair for use inside the home is 
covered if the criteria listed in the Medicare rules section of this letter have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a lightweight wheelchair and elevating leg rests have not been met. Specifically, the case record 
does not contain a wheelchair evaluation to document that you meet criteria for a manual wheelchair. 
Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003) with 
elevating leg rests (K0195).
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 you have provided medical records to support 
authorization for SNF care. The Plan denied your request. The Plan says SNF care is not medically necessary. 
 
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 documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs.  The enrollee is able to ambulate 100 feet and tend to activities of daily 
living with minimal supervision.  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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The documentation does not 
support that the enrollee has tried and failed Euflexxa and Gel-One. The documentation does not support that 
Euflexxa and Gel-One would likely be less effective, and/or would likely have adverse effects for the enrollee 
in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services. You say that has been having many lung issues 
including hospitalizations and has also coughed up blood many times. The Plan denied your request. The Plan 
says that the Plan does not cover services rendered by out-of-network or non-contracted providers unless the 
services are urgent or emergent, prior authorized has been obtained, ambulance services dispatched through 
911, services meeting the continuity of care definition or in the unusual circumstances that the services are not 
available from an in -network contracted 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 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 
physician's services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic queen size mattress (E1399). 
 
You asked the Plan to pre-approve a therapeutic queen size mattress. You say that you have several medical 
conditions, and you are requesting reconsideration and approval of the mattress. The Plan denied your request. 
The Plan says Your records do not show that this item is considered DME because it cannot be used several 
times, meaning it cannot be rented by other people; it is primarily for convenience or comfort; you do not have 
skin ulcers; and you are not using the mattress with a medically necessary hospital bed. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare guidelines state that mattresses are covered only where hospital bed is medically 
necessary. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a therapeutic queen size mattress (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services on March 01, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 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 $250 
copayment for surgery services at outpatient hospital. We cover medically-necessary services you get in the 
outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered service include 
but are not limited to services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery.  
 
 
 
 You have been asked to pay a $250 copayment for outpatient surgery services. Outpatient surgery services 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 
outpatient surgery services on March 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilevel positive airway pressure (Bi-PAP) machine to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a Bi-Pap machine to be provided out of network.. You say that you would 
like this item to be delivered to your new residence. The Plan denied your request. The Plan says the requested 
items are not a covered benefit when provided out of 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 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 
a bilevel positive airway pressure (Bi-PAP) machine to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are requesting a portable 
oxygen concentrator for travel purposes on a cruise. You say that the portable oxygen is necessary. The Plan 
denied your request. The Plan says you were previously approved and provided with a home oxygen system, 
including a home oxygen concentrator and portable oxygen tanks, for your oxygen needs within the home. 
There is no evidence that this equipment is not serving your oxygen needs within the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional home health visits. 
 
You asked the Plan to pre-approve 10 additional home health visits. You say that these visits are necessary for 
recertification. The Plan denied your request. The Plan says additional home health visits are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 10 additional home health visits. Our 
reviewer says that 10 additional home health visits are not medically necessary. Our physician reviewer found 
the enrollee appears to be able to attend wound clinic appointments, bringing into question his homebound 
status.  There is insufficient documentation to show whether the prior care has been beneficial.  As such, the 
requested, ongoing, home health skilled nursing services are not shown to be medically necessary and 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional home health visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 10 additional home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM and supplies. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 
continuous glucose monitor (CGM) and supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the services should be covered because 
the enrollee has diabetes mellitus. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results or have had an in-person visit with their treating physician to assesses adherence to their 
CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for 
coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an endocrinologist (99213) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are almost out of medication, and you have 
seen this doctor in the past. The Plan denied your request. The Plan says you must use network providers to get 
health care and services when there are network 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 office visit with an endocrinologist (99213) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network (OON) skilled nursing 
facility (SNF) care provided from November 18, 2021, to November 30, 2021. 
 
You asked the Plan to waive the coinsurance for the OON SNF care. You say that you were not aware that the 
facility was not in-network. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 30% 
coinsurance for each stay at an out-of-network nursing facility.  
 
The file shows that the Plan verified the facility is not a network facility. Therefore, you have been asked to 
pay $2,337.65, which is 30% of the allowed amount for the OON SNF care ($7,792.16 allowed amount x 30% 
coinsurance = $2,337.65). The OON SNF care falls within the Skilled Nursing Facility (SNF) 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 coinsurance for out-of-network (OON) skilled nursing facility 
(SNF) care provided from November 18, 2021, to November 30, 2021.