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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says The medical records do not support the need for an 
intensive rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per 
week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for stroke and was discharged to skilled nursing on 6/15/22. Medical problems are stable. There are 
no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fully meets criteria for IRF. The Plan 
denied your request. The Plan says the enrollee does not meet criteria and could be treated in a lower level of 
care facility such as a skilled nursing facility, outpatient setting, or home health 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth visit on December 30, 
2021. 
 
You asked the Plan to waive the copayment for specialist telehealth visit. You say that you should have a $0 
copayment for the telehealth visit. The Plan denied your request. The Plan says coinsurance 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 $30 
copayment per visit to a specialist.  
 
You have been asked to pay $30 copayment for the specialist telehealth visit. The specialist telehealth visit falls 
within the Physician/Practitioner services, including doctor's office visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. The telehealth visit needs 
to be arranged by or provided through the BlueCare Anywhere telehealth service. 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 specialist telehealth visit on December 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ground ambulance on February 16, 2022 
 
You asked the Plan to waive the copayment for ambulance. You say that you cannot afford this bill and money 
is tight. The Plan denied your request. The Plan says $200 copay per one-way trip. Covered ambulance services 
include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can 
provide care if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. 
 
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 $200 
copayment per one-way trip.  
 
 
 
 
 
 You have been asked to pay a $200 copayment for ground ambulance. Ground ambulance falls within the 
ambulance services. You have a $200 copayment per one-way trip. The provider billed in the amount of 
$642.43. The approved amount was $497.83, and the plan paid $297.83. Per your benefits, you are responsible 
for a $200 copayment per one-way trip. 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 ground 
ambulance on February 16, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio Flex glucometer and strips. 
 
You asked the Plan to pre-approve OneTouch Verio Flex glucometer and strips. You say that the enrollee 
would prefer One Touch Verio glucometer for monitoring blood glucose. Please approve formulary exception. 
The Plan denied your request. The Plan says there is no evidence that the current glucometer is not working 
properly. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has Foracare system. Foracare system serves the same purpose as OneTouch 
Verio Flex glucometer and strips. Therefore, we decided that the Plan does not have to pre-approve OneTouch 
Verio Flex glucometer and strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty walker to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a heavy duty walker. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the requested out-of-network provider is not contracted in 
the member's network, and they agree that the member's condition makes specialty or service medically 
necessary. They also say that, however, such service is available in network, and there are no extenuating 
circumstances related to geographic access, compelling continuity of care making it medically necessary that 
future care come only from this provider, or unique medically-recognized qualifications of the requested out-
of-network provider to justify prior authorization of out-of-network benefits. 
 
 
 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 heavy duty walker 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 pay for the oxygen concentrator you purchased on October 19, 2021. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you had to purchase a replacement 
concentrator when yours stopped working.  You said you had difficulty finding one in stock and able to ship it 
immediately.  You said that this oxygen concentrator was medically necessary and should be covered. The Plan 
denied your request. The Plan says the provider from whom you purchased this item is not a Medicare-certified 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment providers must be 
Medicare-certified.  Your Evidence of Coverage also advises you that if you get items and services from an 
ineligible provider, you will be responsible for the full cost.  In this case, the durable medical equipment 
company from whom you ordered this item is not a Medicare-certified provider. Based on this information, we 
decided that Medicare rules for coverage of the oxygen concentrator have not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator you purchased on 
October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker insertion. 
 
You asked the Plan to pre-approve a leadless pacemaker insertion. You say that the leadless pacemaker is 
medically necessary for the enrollee's health. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a CMS approved CED study. 
 
We looked at the file and Medicare rules. The case file does not include evidence that the leadless pacemaker 
would be furnished in a CMS approved CED study. Based on this information, we decided that Medicare rules 
for coverage of a leadless pacemaker insertion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a leadless pacemaker insertion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 4, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that appealing the copayment. The 
Plan denied your request. The Plan says you have been charged the correct copayment 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 $50 
copayment for Medicare-covered urgently needed care when services are provided at an in- and out-of-network 
urgent care center.  
 
You have been asked to pay a $50 copayment for an urgent care visit. The urgent care visit 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 an urgent 
care visit provided on January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (71045, 74018) provided on September 
26, 2021. 
 
You asked the Plan to pay for the imaging services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has correctly denied as a 
duplicate of services already paid. 
 
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 payment for CPT codes 71045 and 74018 is not supported in the medical record. Specifically, the 
documentation supports payment for the initial claim that has already processed and paid. The medical records 
in this case do not support payment for services beyond what has already been approved. Based on this 
information, we decided that Medicare rules for coverage of the imaging services have not been met. 
Therefore, we decided that the Plan does not have to pay for the imaging services (71045, 74018) provided on 
September 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided March 3, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you were seen by your primary care 
physician and the Tier 1 copayment of $0 should apply. The Plan denied your request. The Plan says 
coinsurance 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 $15 
copayment for each Tier 2 PCP (standard benefit) Medicare-covered primary care doctor visit.  
 
You have been asked to pay $15 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's 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 office visit provided March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on February 15, 2022. 
 
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 rendered by the out-of-network (OON) provider on 
February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on January 3, 
2022. 
 
You asked the Plan to waive the deductible for the lab services. You say that the lab work should be included 
in your annual visit. The Plan denied your request. The Plan says the correct amount was applied to your 
deductible. 
 
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 $195 deductible which applies to certain items and services.  
 
The lab services received go beyond the scope of a wellness visit, and are subject to the deductible. The lab 
services you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is $195 deductible which applies to certain items and services.  
 
 
 
 
  
This cost sharing is a contractual obligation that had not been met at the time the lab services was received on 
January 3, 2022. Therefore, we decided that the Plan does not have to waive the deductible for laboratory 
services provided on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the nurses said that you should do the three-hour 
rehabilitation treatment instead of the 30 minutes a day of physical therapy. The Plan denied your request. The 
Plan says authorization denied because the IRF care is not medically necessary, and your 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 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 you are medically stable and do not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. You do not need intensive therapies, (speech, physical therapy and occupational therapy) consisting 
of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in 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: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable controller. We decided that the Plan does not 
have to pre-approve a power seat elevation system.  
 You asked the Plan to pre-approve an expandable controller. You say that the enrollee needs these items. The 
Plan says that these items are not necessary.      
 
We decided that the Plan has to pre-approve an expandable controller.  
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is capable operating 3 or 
more powered seating actuators through the drive control. 
 
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 an expandable controller. Our reviewer 
says that the requested expandable controller is medically necessary. Our physician reviewer found the 
documentation shows that 3 power functions (power tilt, power recline, and elevating leg rests) have been 
approved by the Plan. The records also support that the enrollee's condition is progressive in nature for both 
fine motor impairments and upper limb weakness, necessitating the use of the requested controller.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller have been met. Therefore, we decided that the Plan 
has to pre-approve an expandable controller.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that power seat elevation features are non-covered 
because they are not primarily medical in nature.  
 
We looked at the file and Medicare rules. The requested item is not covered. Based on this information, we 
decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system. 
 
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 ophthalmology services provided on November 3, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmology services. You say that as a Medicare Advantage plan, the 
patient's plan covers more than just emergent or urgent care. You also say that you would like the enclosed 
exam notes reviewed for medical necessity for this visit. The Plan denied your request. The Plan says the 
services were determined to be routine, non-urgent/emergent services, performed by an 
out-of-network provider without prior authorization from the health plan. 
 
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 ophthalmology services provided on November 3, 
2021, by an out-of-network (OON) provider.