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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this requested level of care to 
regain independence. The Plan denied your request. The Plan says that the enrollee can safely receive the 
services he needs in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a mitral 
valve replacement because of endocarditis. The enrollees 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. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a denosumab injection (J0897) and office 
visit provided on December 30, 2021. 
 
You asked the Plan to waive the copayment for the denosumab injection and office visit. You say that the 
services should be covered as you disagree with the charges. 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 $40 
copayment for Physician/Practitioner services, including doctors office visits and a 20% coinsurance for 
Medicare Part B prescription drugs, and the administration of them. 
 
 
  You have been asked to pay a 20% coinsurance for a denosumab injection (allowed is $1,271.40 x 20% = 
$254.28) and a $40 copayment for a specialist office visit. 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 denosumab injection (J0897), and office visit provided on December 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room services provided on 
October 13, 2021 and November 17, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
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 $120 
copayment for emergency room services.  
 
You have been asked to pay $240 ($120 copayment x 2) for the emergency room services provided. 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 copayments for the emergency room services provided on 
October 13, 2021 and November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, monaural, in the ear (V5050) provided 
January 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware that you would need prior 
authorization for the hearing aids. The Plan denied your request. The Plan says the hearing aids are not covered 
because they were provided OON without prior authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids when you receive prior authorization before purchasing OON. 
 
We looked at the file and the Plan's rules. The hearing aids in this case were purchased OON without prior 
authorization. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid, monaural, in the ear 
(V5050) provided January 3, 2022, by an out-of-network (OON) provider.  
 Your complaint about not feeling adequately informed about the requirement to get authorization for OON 
benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 7, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it was medically necessary to treat the 
enrollee and an authorization could not be completed in a timely manner. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no approved authorization, and it 
was determined that the services rendered were not urgent or emergent. Also, the services rendered could have 
been provided by an in-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 home health visit provided on October 7, 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 power wheelchair (E1399). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee has been using a wheelchair 
for years to assist her in her daily mobility, activities and tasks. The enrollee indicated that her wheelchair was 
broken, and a replacement was requested. The Plan denied your request. The Plan says the requested item is not 
covered under the enrollees plan. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the clinical notes submitted detail evaluation and treatment for a sinus infection. There is no 
standard written order, no PT assessment/ evaluation, no home evaluation, and no quotation submitted. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $50 
copayment for laboratory services provided at an outpatient hospital.  
 
 
 You have been asked to pay $44.02 for the laboratory services provided at an outpatient hospital. This amount 
is less than the applicable copayment for these services. 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 laboratory services provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on December 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that services rendered to a registered inpatient must 
be billed with POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status and the 
services were not billed with the required POS code 21. Therefore, we decided that the Plan does not have to 
pay for the chest x-ray rendered on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation (99153) provided on August 19, 2021. 
 
You asked the Plan to pay for the moderate sedation. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 99153 was not billed in accordance 
with Medicare guidelines. 
 
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 99153 is not supported in the record. Specifically, CPT code 99153 is a technical 
component only code. Payment for this service is included in the payment to the facility and is the 
responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation have not been met. Therefore, we decided that the Plan does not have to pay 
for the moderate sedation (99153) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on November 12, 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 office visit (99215) rendered by the out-of-network (OON) provider on  
November 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health services. 
 
You asked the Plan to pre-approve the continuation of home health services. You say that home health services 
continue to be medically necessary. The Plan denied your request. The Plan says the criteria for home health 
care is no longer met. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continuation of home health 
services. Our reviewer says that the requested home health services are no longer medically necessary. Our 
physician reviewer found that this case, the documentation does not support that the member requires 
additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. 
The member does not require additional skilled nursing or rehab services to effectively provide treatment, care, 
and/or services in order to improve the members condition, perform a maintenance program to maintain the 
members condition and/or prevent deterioration. The member has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services are not 
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 the continuation of home health services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 13, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee and 
reprocess for payment. The Plan denied your request. The Plan says the rendering provider is an out-of-
network 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 an office visit provided on December 13, 2021, by 
an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 12, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reviewed. The Plan 
denied your request. The Plan says it originally paid the claim incorrectly.  The enrollee's hospice election was 
updated and the Plan confirmed that they were on hospice on the date of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on November 8, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed 
services were not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. The testing request and records provided 
do not show that the enrollees treating physician ordered definitive testing for 15-21 drug classes.  
 Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on 
November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 9, 2021 by an out-of-
network (OON) Gynecologist. 
 
You asked the Plan to pay for the office visit. You say that you have included all necessary information. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 office visit provided on December 9, 2021 by 
an out-of-network (OON) Gynecologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you are paralyzed, and the shower chair is 
medically necessary. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like reconsideration because the SNF 
care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare 
criteria for coverage. 
 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the member does not have any parental 
medication; complex wound care or nutrition given via a feeding tube.  He is medically stable without any 
acute exacerbations of chronic medical problems.  His physical function is at or near his baseline and he can 
receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 
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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skilled Nursing Facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services. 
 
You asked the Plan to pre-approve HHA services. You say that you would like reconsideration because the 
HHA services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 HHA services. Our reviewer says that 
the documentation doesnt support that you require additional skilled nursing services or skilled rehab services 
to provide treatment that is medically necessary. Our physician reviewer found you require custodial care and 
home making services that do not need to be done by a home health aide.  The requested home health services 
are not 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 HHA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide (HHA) services.