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

 
We decided that the Plan does not have to pre-approve a second pair of eyeglasses in 2022. 
 You asked the Plan to pre-approve additional eyeglasses. You say that your current eyeglasses do not work 
well, and you would like an additional/replacement pair. The Plan denied your request. The Plan says you 
previously purchased eyeglasses on February 28, 2022, which exhausted your eyewear benefit for 2022. 
 
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 once every 12 months. 
 
We looked at the file and the Plan's rules. The record shows that you have already used your eyewear benefit in 
2022. Based on this information, we decided that the Plan's rules for coverage of additional eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a second pair of eyeglasses in 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 12, 2021. 
 
You asked the Plan to pay for the lab testing. You say that this is medically necessary testing. The Plan denied 
your request. The Plan says the claim was not billed with an appropriate POS code. 
 
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 lab testing 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 lab testing provided on March 12, 2021.
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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the criteria for an IRF 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 the enrollee's rehab needs can be provided in an alternate and low intensity setting 
such as in an SNF.  
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on February 1, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram reporting (93010) rendered by the out-
of-network (OON) provider on February 3, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the electrocardiogram reporting (93010) rendered by the out-of-network (OON) 
provider on February 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 require skilled nursing or 
therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build-up, including pins (D2950) and the 
porcelain/ceramic crown (D2740) provided by a network provider on October 29, 2021. 
 
You asked the Plan to pay for the core build-up and the porcelain/ceramic crown (D2740). You say that these 
services were medically necessary, and the only practical solution was a crown. You say you could not eat 
functionally without this work. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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, the requested the core build-up, 
including pins (D2950) and the porcelain/ceramic crown (D2740) are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the core build-up, including pins (D2950) 
and the porcelain/ceramic crown (D2740) provided by a network provider on October 29, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested 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 based on the documentation provided the enrollee does not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: 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 lives alone and cannot be sent home 
without care. The appellant says that IRF care is medically necessary. The Plan denied your request. The Plan 
says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in 
another setting. 
 
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 with no new and acute medical conditions. The 
enrollee does not need physical medicine and rehabilitation physician supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. 
There are no acute rehabilitation nursing needs identified or documented in the record. At the current functional 
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. The enrollee needs routine physical therapy and 
occupational therapy in a skilled nursing facility (SNF) or in-home with services. IRF admission is not 
medically necessary based on medical stability and lack of medical complexity, rehabilitation nursing needs 
and high functional level. The documentation provided does not support the medical necessity for admission to 
an IRF. The enrollee's rehabilitation needs can be met safely and provided at a lower intensity and alternate 
setting such as in an SNF or in-home with 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder and a walker holder for a scooter. 
 
You asked the Plan to pre-approve the holders. You say that this is medically necessary. The Plan denied your 
request. The Plan says these items serve no medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 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 cup holder and a walker holder for a scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided August 25, 2021. 
 
You asked the Plan to pay for the dental consultation. You say that this consult was necessary to perform 
additional services. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the results of the CardioMEMS Post 
Approval Study (PAS) demonstrated the effectiveness and safety of PA pressure-guided therapy for heart 
failure in 1200 patients for one year. You say that the recent data from this PAS along with the Champion IDE 
clinical study and the real-world evidence studies, support the clinical benefit of remote hemodynamic 
monitoring. The Plan denied your request. The Plan says the CardioMEMS device is only covered when used 
in a Medicare-approved medical research study. 
 
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 a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for additional physical therapy is 
correct, because it is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there is no documentation to support the requirement of a skilled 
therapist in treating an accepted diagnosis in which a skilled therapist would be needed to assist with 
improvement or stability of a 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional physical therapy visits.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care after May 15, 2022. 
 
You asked the Plan to pre-approve SNF care after May 15, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says that the continued admission to a 
SNF 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. The rules say that Medicare health 
plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its 
decision to deny coverage or payment. 
 
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 after May 15, 2022. Our 
physician reviewer found the health plan argues that you are no longer benefitting from skilled therapy and 
cites your functional status on multiple dates. Therapy records corresponding to these dates are not identified 
for review. As such, the health plan has failed to support its argument. 
 
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 after May 15, 2022, have been met. The Plan must continue coverage 
for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has 
been issued, or the 100-day Medicare benefit is exhausted. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we 
decided that the Plan has to pre-approve skilled nursing facility (SNF) care after May 15, 2022.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy provided from January 19, 
2022, to January 28, 2022. 
 
You asked the Plan to waive the deductible for physical therapy visits. You say that you should have a $35 
copayment for each visit, and this should not be applied to your deductible. The Plan denied your request. The 
Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $600 deductible which applies to outpatient rehabilitation services.  
 
You have been asked to pay $586.08 for the physical therapy visits. The item or service you asked the Plan to 
waive the deductible for falls within the benefit category Outpatient rehabilitation services. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $600 deductible which applies to 
outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time 
physical therapy visits was received from January 19, 2022, to January 28, 2022. Therefore, we decided that 
the Plan does not have to waive the deductible for physical therapy provided from January 19, 2022, to January 
28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for computed tomography scan (CT) and a nuclear 
medicine study provided on January 12, 2022. 
 
You asked the Plan to waive the cost for CT scan and a nuclear medicine study. You say that the plan should 
pay for the scans. The Plan denied your request. The Plan says the deductible and copayment are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to radiological diagnostic services.  
 
 
 
 The item or service you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $750 deductible applies to radiological diagnostic services. This cost sharing 
is a contractual obligation that had not been met at the time CT scan and nuclear medicine study were received 
on January 12, 2022. Therefore, $750 has been applied to meet the deductible. 
 
Since the $750 deductible was met, you have also been asked to pay a $120 copayment for the CT scan. The 
total amount you owe is $870 ($750 + $120 = $870). 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 the Plan does not have to waive the cost for the CT scan 
and nuclear medicine study provided on January 12, 2022.