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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary that the enrollee receive 
SNF care. The Plan denied your request. The Plan says admission to the SNF was not medically necessary and 
treatment in a home setting with care services would benefit the enrollee. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs also there are no 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis 
in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on March 22, 
2022 
 
You asked the Plan to waive the copayment for ambulance. You say that you are disputing the charge 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 $200 
copayment for ambulance services.  
 
You have been asked to pay $200 copayment for ambulance. This item/service falls within the 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 service 
provided on March 22, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on March 
7, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the claim was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 We find that the claim at issue was billed with a place of service code 32. The records show that the services 
were provided during a covered stay. Based on this information, we decided that Medicare rules for coverage 
of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
skilled nursing facility (SNF) services provided on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device and 
supplies purchased on April 8, 2022. 
 
You asked the Plan to pay for the CPAP device and supplies. You say that you would like to be reimbursed for 
this equipment as it is very helpful for your condition when traveling. The Plan denied your request. The Plan 
says payment cannot be made for a separate CPAP machine beyond what has already been covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the continuous positive airway pressure (CPAP) device and supplies purchased on April 8, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast implant removal procedure provided on February 3, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the breast implant removal. You say that in-network providers would not do the 
procedure. The Plan denied your request. The Plan says a referral/authorization was not obtained prior to 
services being rendered. 
 
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 breast implant removal procedure provided on 
February 3, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal trainer fees provided from April 7, 2021, to 
March 31, 2022. 
 
You asked the Plan to pay for the personal trainer fees. You say that you submitted documentation that 
demonstrated you were receiving both individual and group fitness trainings from a certified personal trainer. 
You also say that you believe you should be reimbursed because the program states you choose how you want 
to work out, and the Plan pays you back up to $360 per year. The Plan denied your request. The Plan says your 
fitness benefit does not cover services from personal trainers. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the highlights sheet specifically says 
personal trainers are not covered by the Plan. Therefore, we decided that the Plan does not have to pay for the 
personal trainer fees provided from April 7, 2021, to March 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services on June 29, 2022. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you would like to appeal the 
cost share. 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 $50 
copayment for urgent care services.  
 
You have been asked to pay a $50 copayment for urgent care services. This item/service falls within the 
Urgently needed 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 urgent care 
services on June 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 LTACH is medically necessary. 
 The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a total knee replacement and physical 
therapy. 
 
You asked the Plan to waive the copayment for a total knee replacement and physical therapy. You say that 
there should not be a copayment. 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 $20 
copayment for outpatient rehabilitation services and a $150 copayment for outpatient surgery.  
 
You have been asked to pay a $150 copayment for a total knee replacement and a $20 copayment for physical 
therapy. These service falls within the outpatient rehabilitation services and outpatient surgery benefit 
categories. 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 a total knee replacement and physical 
therapy.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after November 
9, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that you have not seen any improvement since your 
admission. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before November 9, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after November 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cognitive assessment and care plan services provided on  
May 12, 2022. 
 
You asked the Plan to pay for cognitive assessment and care plan services. You say that the services were 
rendered to the member at an assisted living facility and the providers rely on facility staff to verify eligibility 
and obtain authorization from the patients insurance company. The Plan denied your request. The Plan says 
the services were not urgent or emergent and the services could have been rendered by a Plan participating 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 cognitive assessment and care plan services provided on 
May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on April 23, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation did not support the billed code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order or relevant, current, medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor provided on April 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at home coronavirus (COVID-19) tests purchased on January 
6, 2022. 
 
You asked the Plan to pay for at home coronavirus (COVID-19) tests. You say that you were informed before 
purchasing the at home COVID-19 tests that your insurance provider would reimburse you. The Plan denied 
your request. The Plan says testing is covered when provided by a network provider, medically necessary and 
ordered by a physician. The Plan also says they contacted your primary care physician (PCP) office, who 
indicated that they did not refer you to obtain a test. 
 
The Plan must follow Medicare rules. Medicare rules say that they will cover up to eight over-the-counter 
COVID-19 tests each calendar month as of April 4, 2022.  
 
 We looked at the file and Medicare rules. The record shows these tests was purchase before April 4, 2022. 
Based on this information, we decided that Medicare rules for coverage of at home coronavirus (COVID-19) 
tests have not been met. Therefore, we decided that the Plan does not have to pay for at home coronavirus 
(COVID-19) tests purchased on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 6, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the codes are 
not separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The medical records provided do not show that the services billed with the -
59 modifier are a distinct procedural service. We also find that the testing described by billed code 83986 is 
considered specimen validity testing which is not separately payable.  Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on April 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on September 26, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that the paramedics did not want to take you to 
the hospital because of COVID-19. The Plan denied your request. The Plan says this service is not covered 
when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on September 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on September 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from January 5, 2022, to 
January 15, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that it was appropriate to attempt to maximize the 
enrollee's medical condition prior to surgery. The Plan denied your request. The Plan says that the services 
could have been provided during the first admission. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 inpatient services. Our physician 
reviewer found that the enrollee has a history of heart failure, non-ST-elevation myocardial infarction 
(NSTEMI), aortic stenosis and end stage renal disease, leading to admission and treatment in the hospital from 
December 18, 2021, 50 December 30, 2021. He was recommended a transcatheter aortic valve replacement 
(TAVR) surgery for the aortic stenosis, which was not emergent. He was sent home, stable, to gain strength 
prior to undergoing surgery, which is reasonable. However, unexpectedly, he declined at home following 
dialysis with worsening shortness of breath. He was readmitted and underwent the TAVR surgery earlier than 
planned. The readmission was medically necessary. The enrollee had acute respiratory distress and required 
inpatient treatment. The readmission did not result from a premature discharge from the same hospital as he 
was stable on discharge and was expected to continue to improve 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 the inpatient services have been met. Therefore, we decided that the Plan has to 
pay for the inpatient hospital services provided from January 5, 2022, to January 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says it is very important to get a written referral (approval in advance) from the 
enrollees primary care provider (PCP) before the enrollee sees a plan specialist or certain other providers 
(there are a few exceptions, listed in Section 2.2 above). If the enrollee does not have a written referral 
(approval in advance) before they get services from a specialist, the enrollee may have to pay for these services 
themself. 
 
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 
office visit 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 Duloxetine. 
 
You asked the Plan to pre-approve Duloxetine. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says they do not administer pharmacy benefits for the 
enrollee. 
 
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 pre-approve Duloxetine.  
 
Benefits for Duloxetine 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iluvien. 
 
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. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 the enrollee has focal chorioretinal 
inflammation of posterior pole and puckering of macula. The Food and Drug Administration (FDA) has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
Iluvien is 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 Iluvien.