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

 
We decided that the Plan does not have to pay for the hearing aids provided on December 7, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were told the Plan would pay through the 
reimbursement process. The Plan denied your request. The Plan says these hearing aids were rendered by a 
non-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 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 
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 hearing aids provided on December 7, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no support in the documentation 
that the enrollee requires the intensive medical care and the intensive rehabilitation therapy program provided 
in an inpatient rehabilitation facility. The medical records do not clarify that treatment at the skilled nursing facility level is not appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
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 (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that the enrollee's next step in 
treatment would be to add a short acting insulin. He is unable to care for himself and his medications are 
administered by a nurse. The enrollee would benefit from a CGM to alert him and staff to low blood sugar 
readings and allow for closer monitoring and medication adjustments as needed. The Plan denied your request. 
The Plan says the enrollee does not meet authorization 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 or 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 (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and the debridement of 
subcutaneous tissue provided from April 8, 2022, to May 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care and the debridement of subcutaneous tissue. You 
say that this provider is the only wound specialist that works for the nursing home. You also say that the 
provider saw the patient under the impression that there is an authorization on file. The Plan denied your 
request. The Plan says services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care, and the 
debridement of subcutaneous tissue provided from April 8, 2022, to May 6, 2022, by an out-of-network (OON) 
provider.
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 
April 27, 2022, to May 3, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you should 
not have to pay a copayment for your hospital stay. You say that your hospital stay was a result of an incident 
that occurred while walking into an orthopedic office. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 
copayment for each day for days 1-5, then $0 copayment per day after day 5.  
 
You have been asked to pay $1,850 for an inpatient hospital stay ($370 copayment per day x 5 days = $1,850). 
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 April 27, 2022, to May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), drug test, definitive (G0481), and 
drug test, presumptive (80307) provided on May 3, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the physician services. You say that  The Plan denied your request. The Plan says 
the claim processed correctly. 
 
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 in this case is not a network provider with the Plan. 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 (99214), drug test, definitive (G0481), and drug 
test, presumptive (80307) provided on May 3, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that your cast will be removed on Wednesday and you 
will need physical therapy to be able to walk again and build strength and endurance. The Plan denied your 
request. The Plan says the requested service is not reasonable and necessary and does not meet Medicare 
criteria for SNF 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 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 have a past medical history of a left foot triple arthrodesis and Achille's tendon 
lengthening, hypertension, hypothyroidism and atrial fibrillation who presented to the acute hospital on 
September 6, 2022 with abdominal pain. You were treated in the hospital with enemas and laxatives for a fecal 
impaction and your condition has stabilized. You are weak and deconditioned and are working with physical 
and occupational therapy. You are non-ambulatory and non-weight bearing with your left lower extremity and 
is dependent for transfers and some activities of daily living. You are otherwise is reported to be medically 
stable for discharge on outpatient medications. You do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you provided services to the enrollee in good faith 
and expect payment for the services rendered. The Plan denied your request. The Plan says the services the 
enrollee received were not urgent or emergent and nor were they approved in advance. The Plan says payment 
cannot be made to an out-of-network provider without meeting these criteria. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal.  
 
 
 The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit 
provided on April 19, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were told an authorization was not needed and 
you would like the claim reprocessed. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on November 27, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone amplifier (V5268) and television amplifier 
(V5270) provided on March 2, 2022, and March 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telephone amplifier and television amplifier. You say that you feel you 
should be reimbursed for this because in May of 2019, you were reimbursed for the hearing aids you 
purchased. The Plan denied your request. The Plan says you received these items from an OON provider. The 
Plan also says that you did not contact the Plan for the purchase of your hearing aids, and your benefits have 
changed since 2019. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the telephone amplifier and television amplifier have not been met. Therefore, we decided that the 
Plan does not have to pay for the telephone amplifier (V5268) and television amplifier (V5270) provided on 
March 2, 2022, and March 4, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) on August 1, 
2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). The Plan denied your request. The 
Plan says the service is not supported without the requested documentation. 
 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hospital discharge day management 
(99239) have been met. Specifically, medical records for the discharge management services were not 
submitted. Therefore, we decided that the Plan does not have to pay for hospital discharge day management 
(99239) on August 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 2, 
2021, to December 7, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was warranted. The Plan 
denied your request. The Plan says the medical records do not support an acute inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient is a 72 year-old female with chronic obstructive pulmonary disease 
(COPD) on three liters of home oxygen who presented to the emergency room (ER) with cough and shortness 
of breath. Her pulse oximetry was 79% on room air at home according to the patient. She was given 
bronchodilators, oxygen, IV steroids, and magnesium. Following initial early treatment, her breathing 
improved back to baseline. She had a chest x-ray that was similar to prior imaging. She was admitted and 
diagnosed with a mild COPD exacerbation and was switched to oral prednisone taper after admission. Based on 
the quick response from initial treatment in the ER and no complexities, signs of infection or other factors that 
would expect a prolonged hospital stay, it was not expected that the patient would require hospital care that 
would likely cross two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 2, 2021, to December 
7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rhytidectomy surgery. 
 
You asked the Plan to pre-approve rhytidectomy surgery. You say that the enrollee has lost over 100 pounds 
since having gastric sleeve surgery and has a lot of skin hanging. You say that it is medically necessary that the 
hanging skin is removed. The Plan denied your request. The Plan says the requested procedure is cosmetic in 
nature and not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 rhytidectomy surgery. Our reviewer 
says that the criteria for coverage have not been met. Our reviewer found the record indicates that the enrollee 
has had weight loss and requests revision of previous facelift.  The requested procedure is cosmetic in nature.  
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of rhytidectomy surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve rhytidectomy surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Provenge (Q2043). 
 
You asked the Plan to pre-approve Provenge. You say that the enrollee would benefit from immunotherapy. 
The Plan denied your request. The Plan says the enrollee does not meet the guidelines for Provenge treatment. 
 
The Plan follows Medicare rules. Medicare rules say that the use of autologous cellular immunotherapy 
treatment - sipuleucel-T; Provenge improves health outcomes for Medicare beneficiaries with asymptomatic or 
minimally symptomatic metastatic castrate-resistant (hormone refractory) prostate cancer, and is reasonable 
and necessary for this on-label indication. 
 
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 Provenge. Our reviewer says that 
Provenge is not reasonable and necessary for the enrollee. Our physician reviewer found the record indicates 
that the enrollee has a diagnosis of prostate adenocarcinoma stage T1c. The record indicates that the enrollee 
has responded to hormonal therapy and has castrate sensitive disease. Our reviewer found that the elements of 
the coverage criteria are not satisfied, and the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Provenge have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Provenge (Q2043).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 13, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on May 13, 2022, by an out-
of-network (OON) provider.