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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH 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 be safely administered at the current facility until more appropriate for a lower level 
of care. The enrollee does not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that the patient requires that are not already available and covered 
at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ophthalmologist services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Ophthalmologist services. You say that you would like to appeal the denial 
of the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received 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 items/services. Therefore, we decided that the Plan does not have to pre-approve 
Ophthalmologist 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 three (3) extra batteries for the portable oxygen 
concentrator (CPT code E1356). 
 
You asked the Plan to pre-approve the batteries. You say that the Simply Go oxygen only gives you an hour of 
air which does not allow you to complete your daily activities. The Plan denied your request. The Plan says the 
items are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the batteries have not been met. The records show that you have 
been provided a stationary oxygen concentrator and a portable oxygen concentrator (POC) in March 2022, to 
meet your needs for supplemental oxygen. As per The Centers for Medicare and Medicaid Services (CMS) 
LCD for Oxygen and Oxygen Equipment (L33797), Medicare does not provide coverage for POC batteries as 
the item itself, the POC, can be recharged. When a POC is authorized, it includes the device itself, and an 
integrated battery or beneficiary-replaceable battery. Medicare does not cover an extra set of batteries. 
Therefore, we decided that the Plan does not have to pre-approve three (3) extra batteries for the portable 
oxygen concentrator (CPT code E1356).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pain Management services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Pain Management services. You say that you would like to see a specific 
provider that is OON. The Plan denied your request. The Plan says you need a referral from your primary care 
provider (PCP). 
 
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 
Pain Management 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 cold therapy machine (99999). 
 
You asked the Plan to pre-approve the cold therapy machine. You say that this device is medically necessary. 
The Plan denied your request. The Plan says this device is non-covered under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. This device is non-covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the cold therapy machine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a cold therapy machine (99999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mammography to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a mammography. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the services have been requested from an out-of-network 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 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 mammography to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nail debridement to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal.  We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the 
Plan does not have to pre-approve nail debridement to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you expect that the enrollee will require 
another two to three weeks to transition from their acute illness. The Plan denied your request. The Plan says 
the stay is not medically necessary based on LTACH 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 stable but requires only short-term additional acute care 
services that can be safely administered at the current facility until more appropriate for a lower level of care. 
The enrollee does not require services at the LTACH that are not already available at the current facility. There 
are no services at the LTACH that the patient requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POC (CPT code E1392). 
 
You asked the Plan to pre-approve the POC. You say that your current oxygen concentrator must be carried 
around your neck and it is causing you considerable pain in neck and shoulders. The Plan denied your request. 
The Plan says the medical information provided by your treating practitioner does not indicate any limitations 
that would prevent you from using the POC that was already provided to you for your supplemental oxygen 
needs. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the POC have not been met. The records show that you have been 
provided a stationary oxygen concentrator and portable oxygen tanks in May 2020, and a POC in July 2020, 
with exchanges in December 2020, and August 2021, to meet your needs for supplemental oxygen. As per the 
Centers for Medicare and Medicaid Services (CMS) LCD L33797, Medicare and the health plan provide 
coverage for portable oxygen systems if you are mobile within the home; however, does not specify the type or 
portable oxygen that must be dispersed. Medicare does not provide coverage for POC batteries as the item 
itself, the POC, can be recharged. When a POC is authorized, it includes the device itself, and an integrated 
battery or beneficiary-replaceable battery. Medicare does not provide duplicate equipment, or two (2) pieces of 
equipment to meet the same medical need. Therefore, we decided that the Plan does not have to pre-approve 
the POC (CPT code E1392).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an inpatient hospital stay provided from October 10, 
2021, to October 13, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that your husband called the 
insurance company and confirmed you would not be charged a cost share while in the hospital with COVID-
19. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount. 
The Plan also says that the waiving of cost shares for COVID-19 treatment at an inpatient place of service 
ended on March 31, 2021. 
 
The Plan must follow Medicare rules. 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide documentation on when the cost share waiver expired 
for inpatient COVID-19 treatment. Without the documentation we are unable to determine if the cost sharing 
applied is correct. Therefore, we decided that the Plan has to waive the copayment for an inpatient hospital stay 
provided from October 10, 2021, to October 13, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the services have been requested from an out-of-network 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 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 to be provided by an out-of-network (OON) provider.
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 your mother needs inpatient rehabilitation to regain 
some form of independence. You say that she is a dialysis patient and greatly needs rehab. The Plan denied 
your request. The Plan says the enrollee can safely receive services in other settings. 
 
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 enrollee does not require close supervision 3 times per week and no rehab 
nursing needs were identified or documented in the record. While the enrollee may benefit from physical or 
occupational therapy, the enrollee's rehab can be safely provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on August 16, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that the MRI should be covered. The Plan 
denied your request. The Plan says the copayment applied 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 an in-
network $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays, 
performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 You have been asked to pay a $110 copayment for the MRI. An MRI falls within the Outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the MRI provided on August 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistance services (T1019). 
 
You asked the Plan to pre-approve personal care assistance services. You say that this care is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this care is not covered by Medicare or by the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care assistance services have not been met. Specifically, we find that the services at issue 
in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
personal care assistance services (T1019).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on October 12, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that you are a portable x-ray provider, and it is impossible to 
get a prior authorization. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers and there was no 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 x-ray provided on October 12, 2021, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Portable x-ray services provided on November 19, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Portable x-ray services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Portable x-ray services provided on November 19, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an otolaryngology specialist office visit 
provided on December 20, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were waiting 36 
minutes for the provider, and she was only in the room with you for 5 minutes. You also say you should not 
have to pay this bill. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for a specialist office visit.  
 
 You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit 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 otolaryngology specialist office visit provided on December 20, 
2021.  
 
Your complaint about the amount of time the provider was in the room with you is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutritional counseling. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the requested services are 
necessary to achieve the best outcomes in treatment of her cancer. The Plan denied your request. The Plan says 
the service at issue is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve medical nutritional counseling.