Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 15, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel that the copayment is too 
high and would like to have the copayment waived/ 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit provided on September 15, 2022.
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 enrollee meets admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requirements for admission to an IRF 
have 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 the enrollee is medically stable and does not need physician supervision three 
times a week in an IRF. There are no acute rehab nursing needs identified in the documentation. At the current 
level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 
days per week with multidisciplinary approach in an IRF. Needs can be provided for in a lower intensity and 
alternate setting such as in a skilled nursing facility (SNF) with intermittent therapies. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON physical therapy services. You say that the enrollee was referred 
to your office by an in-network provider. You say that this in-network provider referred the enrollee to your 
office because they knew that your office would schedule the enrollee without delay. You say that due to the 
enrollee's condition, lack of transportation, and under the circumstances of COVID-19, the enrollee is not able 
to go to other offices. You say that you are in-network with Medicare and are willing to accept a Medicare 
payment rate. You say that the enrollee would need to wait 3-4 weeks to begin treatment with a network 
provider. The Plan denied your request. The Plan says medically necessary care is available in-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 services with an out-of-network provider. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy services 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 MyoPro orthosis. 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that the records provided support the need for 
the requested device. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro orthosis. Our reviewer says 
that a MyoPro orthosis is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes for this 
patient.  There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro orthosis.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven additional home health visits. 
 
You asked the Plan to pre-approve home health services. You say that you are appealing with records. The Plan 
denied your request. The Plan says the services 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you have 
a chronic stable condition with no stable vital signs. There is no indication for continued observation or skilled 
nursing intervention. There have been no medication adjustments. There are no skilled needs beyond what has 
already been provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven additional home health visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is 
medically necessary. The Plan denied your request. The Plan says the procedure is currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require 
a greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found the enrollee is experiencing pain in her left shoulder, affecting ADLs. 
imaging and clinical exam support glenohumeral osteoarthritis. She has tried and failed conservative measures. 
The enrollee is undergoing a planned elective left shoulder surgery. She is medically stable with a past medical 
history of Hypothyroid, OA, HLD, COPD, and depression. The planned procedure listed under cpt code 23472 
is not listed on the CMS inpatient only list. The procedure is currently approved as an ambulatory procedure. 
There is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. The review has determined that the record did not show that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span 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 pre-approve acute inpatient hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide or certified nurse assistant, per visit 
(T1021). 
 
 
 
 You asked the Plan to pre-approve home health services. You say that you recently had surgery and had your 
big right toe amputated, in addition to having surgery in the same leg for a vein replacement due to poor 
circulation which had caused the gangrene on your foot. You live alone with your husband who also recently 
had surgery. You cannot bathe yourself or use the restroom on your own. Your daughter assists you in the 
morning before she goes to work and comes back home after 7:00 PM. Therefore, you choose to sit on the 
toilet all day which is not good for your health because you must have your legs elevated. The Plan denied your 
request. The Plan says the services 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that the health aide services meet Medicare criteria for 
reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. Provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any skilled nursing visits or skilled therapy visits. Records do not document the need for 
intravenous medications, new tube feeding, or ostomy care or daily complex wound care. Without the need for 
skilled nursing or therapy services, Medicare does not cover home health aide services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide or certified nurse assistant, per visit (T1021).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient metal health services provided on March 13, 2022. 
 
You asked the Plan to pay for outpatient metal health services. You say that the services should be paid by 
secondary insurance. 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 outpatient metal health 
services provided on March 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not 
meet 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 continued 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 injured her upper extremity and began daily skilled 
therapy on February 7, 2023. By February 16, 2023, she was walking 200 feet supervision to CGA and 
toileting with supervision to CGA. Daily skilled therapy is not necessary to restore or maintain function as she 
is able to progress with repetitive exercise and support from non-skilled personnel. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided on September 29, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you exhausted your benefit. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2391) provided on 
September 29, 2022.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for a 
lower level of care. There are no services available at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary at this time as it 
would not be clinically advantageous. Completion of treatment at the current facility is 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from November 16, 2022, 
through November 17, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you had no idea what drugs were provided 
or their purpose. You say that any drugs you received were provided by the medical staff and were not told that 
it may not be covered by your Plan. The Plan denied your request. The Plan says self-administered drugs do not 
fall under Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from November 16, 2022, through November 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility visit provided on August 01, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility visit. You say that it is the responsibility of the 
facility to obtain authorization. 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 visit provided on August 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate rectal spacers. 
 You asked the Plan to pre-approve prostate rectal spacers. You say that the medical records provided support 
the need for prostate rectal spacers. The Plan denied your request. The Plan says prostate rectal spacers are only 
considered medically reasonable and necessary when the enrollee has low or favorable intermediate risk 
prostate cancer. 
 
The Plan follows Medicare rules. Medicare rules say that prostate rectal spacers are covered for enrollees who 
meet certain inclusion criteria. Medicare rules say that enrollees must be part of a Low or Favorable 
Intermediate Prostate Cancer Risk Group in order to be covered for prostate rectal spacers. 
 
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 prostate rectal spacers. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has 
unfavorable intermediate risk 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 prostate rectal spacers have not been met. Therefore, we decided that the Plan 
does not have to pre-approve prostate rectal spacers.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to care for yourself. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.