Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81001, 87086) rendered by the out-
of-network (OON) provider on October 15, 2021 and October 19, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (81001, 87086) rendered by the out-of-network (OON) 
provider on October 15, 2021 and October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) provided on October 
29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a portable oxygen concentrator. You say that you depend on oxygen all the time 
and cannot go anywhere without it. You also say that kids invite you over, but you cannot go because you need 
oxygen at all times. The Plan denied your request. The Plan says it was determined that a portable oxygen 
concentrator was rendered with a non-contracting 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 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 a portable oxygen concentrator (E1392) provided 
on October 29, 2021, 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 home ventilator (E0466) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a home ventilator. You say that you are appealing with supporting 
documents. The Plan denied your request. The Plan says the requested provider is an out-of-network provider 
and there are in-network providers available who can supply 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 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 home ventilator (E0466) 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 pay for the hospital outpatient clinic visit (G0463) rendered by the 
out-of-network (OON) provider on November 24, 2021. 
 
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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) 
provider on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a urogynecologist to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with a urogynecologist. You say that you want to still be able 
to see your providers at this facility, and your providers are specifically urogynecologists. You also say that 
you have to see only them. You also say that the Plan only has a male urogynecologist and you only feel 
comfortable with a female doctor. The Plan denied your request. The Plan says there is no evidence of 
exhaustion of all gynecologist in-network resources, and there are in-network gynecologist specialists who can 
see the member for her issue of Pelvic Organ prolapse. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with a urogynecologist to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that iron infusion therapy is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation that the 
enrollee meets the criteria for Venofer infusions. The most recent laboratory data dated March 18, 2022 states 
that he has a hemoglobin level of 13.1 grams/dl, ferritin 116 ng/ml, iron 76 mcg/dl, TIBC 289 mcg/dl and 
transferrin saturation 26 percent. These values do not support a diagnosis of iron deficiency anemia to 
necessitate treatment with Venofer infusions. The services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Venofer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator to be used for the treatment 
of chronic obstructive pulmonary disease (COPD) and restrictive thoracic disorder. The Plan denied your 
request. The Plan says the request for a home mechanical ventilator set in intelligent volume-assured pressure 
support (IVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. This patient has COPD and thoracic kyphosis and 
has had repeated exacerbations of the COPD. The most recent hospitalization showed acute hypercarbic 
respiratory failure, but there is no evidence for chronic hypercarbic respiratory failure. There is no arterial 
blood gas (ABG) showing carbon dioxide (CO2) retention while the patient is awake and stable as an outpatient. There are no pulmonary function tests to determine whether there is restrictive disease. BiPAP has 
not been tried at home. Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from March 
5, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found this enrollee does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of March 5, 2022, forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant 
while not showing any acute threats to safety as the enrollee awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from March 5, 2022, forward.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on March 19, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that these services were medically necessary 
and the claim should be reprocessed. The Plan denied your request. The Plan says air ambulance services were 
not medically necessary. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the air ambulance services. Our reviewer 
says that air ambulance services were not medically necessary. Our physician reviewer found the enrollee 
presented to the emergency room on after she experienced "near syncope and fatigue." She has a significant 
medical history of "non sustained ventricular tachycardia" and has previously had an ablation performed at the 
receiving facility. After an evaluation, it was determined that the patient needed to be transported to a facility 
better equipped to care for her based on her critical diagnosis. Your organization was contacted to transport the 
patient via emergent air ambulance to the sending facility for "interventional cardiology" services. The 
reviewed documentation indicates that the patient was not in critical condition. She had stable vital signs. There 
was no evidence of acute unstable medical conditions requiring emergent intervention. The review has 
determined that the documentation did support that the patient suffered from an illness or injury that 
contraindicated transportation by any means other than ambulance. The documentation did not support that the 
patient's condition was such that the time needed to transport a patient by ground, or the instability of 
transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. 
The documentation did not support that the transferring hospital did not have adequate facilities to provide the 
medical services needed by the patient. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on March 19, 2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided you only require short-term additional acute 
care services that can safely be administered at the current facility. You do not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that you require that 
are not already available and covered at the current facility. 
 
   
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
22, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the copayment should be 
waived because you needed a higher level of care. The Plan denied your request. The Plan says the copayment 
amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each separate Medicare-covered ambulance service.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
each Ambulance Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
services provided on October 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on September 17, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that these services were rendered in good 
faith. The Plan denied your request. The Plan says air ambulance services were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  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 the air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the patient 
had a syncopal episode and fell to the ground in his driveway, striking his head. According to the records, the 
patient had no signs of trauma on his head and no fluids or foreign objects in his ears, nose, or mouth. The 
patient was able to speak in full sentences and had clear and equal lung sounds. The patient was transported via 
helicopter to the receiving facility. The doctor found that the documentation did support that the patient 
suffered from an illness or injury that contraindicates transportation by any means other than ambulance. The 
documentation did not support that the patient's condition was such that the time needed to transport a patient 
by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously 
endangered the patient's health. The documentation did support that the transferring hospital did not have 
adequate facilities to provide the medical services needed by the patient. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on September 17, 2021.
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 enrollee will need continuous 
intravenous and respiratory therapy and is exhibiting pressure ulcers which will need treatment. You say that 
enrollee is stable and suitable for transfer to an LTACH. The Plan denied your request. The Plan says the 
necessary services could be provided in another setting. 
 
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 that the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility.  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 enrollee requires that are not already available and covered at the current 
facility. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy and biopsy performed on 
October 18, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy and biopsy. You say that the services should 
be covered as it was a screening procedure. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $300 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $300 copayment for a colonoscopy and biopsy. The record indicates that this 
became a diagnostic procedure because it turned into a biopsy and removal of a lesion or grown. Colonoscopies 
and biopsies fall within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 
colonoscopy and biopsy performed on October 18, 2021.