Persius/hicric huggingface dataset:
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 the enrollee has been working with physical therapy 
and occupational therapy and was deemed to be a great candidate for IRF admission for optimal functional 
recovery. The Plan denied your request. The Plan says the enrollee does not meet criteria for acute rehab stay 
and the enrollees needs can be met at a lower level of care. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program, such as an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute 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 power wheelchair (K0836). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the information sent in does not show that you cannot use a walker or a 
cane within your home for your activities of daily living (mobility related activities of daily living). 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair is medically necessary if all the 
criteria listed in the Medicare Rules section is 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 power wheelchair. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found your are able to ambulate within the 
home with a walker with a seat and there is no indication that you require a PWC to accomplish mobility-
related self-care tasks. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (K0836).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided from 
November 20, 2021, to November 22, 2021. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you would like the 
hospital stay covered. The Plan denied your request. The Plan says the coinsurance was 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 20% 
coinsurance for each Medicare-covered hospital stay.  
 
 
  You have been asked to pay a total of $1,203.30 for the inpatient hospital stay (allowed amount = $6,016.50 x 
20%= $1,203.30). An inpatient hospital stay falls within the Inpatient Hospital Care 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 coinsurance for the inpatient hospital stay provided from November 20, 
2021, to November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary due to the 
enrollee's low blood sugar. The Plan denied your request. The Plan says the requirements for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you were told that the referral and authorization was 
taken care of. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 office visit provided on January 11, 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 the diabetic shoes to be provided by an OON provider. 
 
You asked the Plan to pre-approve the diabetic shoes. You say that there is no other provider in the area that 
supplies the diabetic shoes that are needed. The Plan denied your request. The Plan says there are multiple in-
network providers that are within a reasonable distance from the enrollee's location that can provide the item. 
 
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 
the diabetic shoes to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous sacroplasty procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there 
are not enough studies to show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the sacroplasty services are experimental. More research is needed to show safety and 
efficacy for sacral insufficiency fractures. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a percutaneous sacroplasty procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the requested provider is out of the Plan's network, however, there are 
providers in your network who can help with this 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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Physical Therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Physical Therapy. You say that the services requested are medically 
necessary. 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 
Physical Therapy to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 25, 2021, to December 24, 2021. 
 
You asked the Plan to pay for home health services. You say that the claim was wrongly denied as untimely. 
The Plan denied your request. The Plan says the RAP claim was not submitted within 5 days of the start of 
care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, November 25, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 25, 2021, to 
December 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
September 6, 2021, to September 22, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this 
bill. The Plan denied your request. The Plan says the copayment was 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 a $320 
in-network copayment per day for days 1-5 and a $0 copayment per day for days 6 and beyond for the inpatient 
hospital stay. 
 
 You have been asked to pay a total of $1,600 ($320 copayment x 5 days = $1,600). An inpatient hospital stay 
falls within the Inpatient hospital care 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 inpatient hospital stay provided from September 6, 2021, to September 22, 2021.
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 would like to see a specific provider that is 
OON. 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 
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 pay for initial hospital care (99222) billed for date of service 
December 10, 2021.  
You asked the Plan to pay for initial hospital care. You say that you have provided medical records to support 
the level of service. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the record shows that the 
enrollee was admitted and discharged within less than 24 hours but equal to or greater than 8 hours. The rules 
say that, in this scenario, services from CPT code range 99234-99236 shall be reported. CPT code 99222 is not 
within the required code range. Based on this information, we decided that Medicare rules for coverage of 
initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial 
hospital care (99222) billed for date of service December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sit-to-stand system. 
 
You asked the Plan to pre-approve the requested service. You say that it is easier to maneuver than a Hoyer lift. 
The Plan denied your request. The Plan says the item is non-covered. 
 
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 sit-to-stand system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a cardiology specialist office visit and an 
echocardiogram provided on November 17, 2021. 
 
You asked the Plan to waive the cost share for a specialist office visit and an echocardiogram. You say that the 
amount is wrong, and this should be paid. 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. Your 
contract with the Plan says that there is $250 deductible which applies to an out-of-network echocardiogram. 
The Plan contract also says that the enrollee must pay a $25 copayment for an out-of-network specialist office 
visit. 
 
 You have been asked to pay $199.60, which was applied to your deductible. The echocardiogram you asked the 
Plan to waive the cost share 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 there 
is $250 deductible which applies to an out-of-network echocardiogram. This cost sharing is a contractual 
obligation that had not been met at the time an echocardiogram was received on November 17, 2021.  
 
You have been asked to pay a $25 copayment for a specialist office visit. A specialist office visit falls within 
the Physician/Practitioner Services, Including Doctors Office Visits benefits category. You have been asked to 
pay a total of $224.60 ($199.60 deductible + $25 copayment = $224.60). 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 cost share for a cardiology specialist office visit and an echocardiogram provided on November 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Targeted case management to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Targeted case management. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services were 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 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 
Targeted case management 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 psychotherapy services provided from October 19, 2021, 
to October 26, 2021, by an OON provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that no authorization is needed based on 
your contract and you would like the claim reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
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 the psychotherapy services provided from October 
19, 2021, to October 26, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
October 13, 2021. We also decided that the Plan does not have to waive the copayment for a myocardial 
perfusion imaging (SPECT) and the coinsurance for Tc-99m contrast agent injection provided on October 22, 
2021. 
 You asked the Plan to waive the copayments and coinsurance for the ECG, SPECT, and contrast agent. You 
say that you do not know why these services were not fully covered. The Plan denied your request. The Plan 
says the correct copayments and coinsurance were applied. 
 
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 $15 
copayment for non-radiological diagnostic services, including ECG's. 
 
Your contract with the Plan also clearly says that you must pay a $125 copayment for radiological diagnostic 
services, including SPECT tests. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for medical supplies, 
including contrast agents. 
 
You have been asked to pay a $15 copayment for the ECG. You have also been asked to pay a $125 copayment 
for the SPECT test, and $4 for the Tc-99m contrast agent, which is 20% of the allowed amount ($20 allowed 
amount x 20% coinsurance = $4). The total for all services is $144. The ECG, SPECT, and contrast agent fall 
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 an electrocardiogram (ECG) provided on October 13, 2021. We also 
decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging (SPECT) and 
the coinsurance for Tc-99m contrast agent injection provided on October 22, 2021.