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

We decided that the Plan does not have to pre-approve SNF services to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are able to go to an in-network facility in New Mexico for continued nursing care and rehabilitation. You do not need to go out of state for your care.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve SNF services to be provided by the requested out-of-network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on December 17, 2020. 
 
You asked the Plan to pay for the drug testing. You say that the records support the billing of this testing. The 
Plan denied your request. The Plan says this was not billed with an appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on December 17, 2020.
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 LTACH is the appropriate level of care 
for the enrollee, and he is medically stable to be transferred. The Plan denied your request. The Plan says under 
Medicare, your request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis.  
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from April 17, 2021, 
through May 16, 2021. 
  
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
continuation of SNF services is not medically necessary. 
 
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 pay for continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective the enrollee received oral medications. The enrollee had stable vital signs. Her oral intake was 
good. Her labs were monitored. Regarding rehabilitation services, the enrollee did not require nor receive 
skilled therapy for the dates in question. There are no identifiable skilled nursing service needs. There are no 
identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a 
daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of SNF services provided from April 17, 2021, through 
May 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair footplate brackets, calf pads, hand pads, and 
a retractable lap belt (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the requested items are included in the base code for 
the powered wheelchair and are not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that code K0108 must not be used for items that have 
a specific HCPCS code or are already included with another code. 
 
We looked at the file and Medicare rules. The requested accessories (foot pads, foot brackets, hand pads, and a 
lap belt) are included in the base wheelchair code (K0856). These accessories are not separately payable per 
Medicare rules. Deluxe hand pads are not covered. The base wheelchair code includes the covered standards 
hand pads. Based on this information, we decided that Medicare rules for coverage of the wheelchair 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair 
footplate brackets, calf pads, hand pads, and a retractable lap belt (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient evidence at this time to make a recommendation for or against the 
placement of an interspinous process spacing device in patients with lumbar spinal stenosis. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found these interspinous process distraction devices are experimental. More research is needed to show safety 
and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
April 22, 2021, to April 23, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that this copayment should be waived 
because you were admitted to the hospital the same day. The Plan denied your request. The Plan says you were 
charged this copayment 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 $90 
copayment for emergency room visits.  
 
You have been asked to pay a $90 copayment for the ER visit. Billing records show that you were not admitted to the hospital as an inpatient.  Rather, you were kept in a 24-hour observation status, which is an outpatient 
status. 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 emergency room (ER) visit you had on 
April 22, 2021, to April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0465, E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the record indicates a 
diagnosis of chronic obstructive pulmonary disease (COPD), but there are no pulmonary function tests for 
confirmation.  The patient is severely obese and obesity-hypoventilation syndrome is suspected.  The patient 
has obstructive sleep apnea. A bi-level positive airway pressure (BiPAP) device has not been tried at home.  
This patient may benefit from BiPAP support at night, and certain BiPAP devices can provide the average 
volume-assured pressure support (AVAPS) mode of support at less cost for the patient than a ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0465, E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture (D5212). 
 
You asked the Plan to pre-approve the lower partial denture (D5212). You say that the patient lost her partial 
and she cannot eat properly without it. You say that she is missing several lower teeth that the partial will 
replace, and the service should be reconsidered for payment. The Plan denied your request. The Plan says this 
service has exceeded the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one lower partial denture every five plan years. The Plan paid for the lower partial denture provided on 
November 14, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-
approve the lower partial denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional positive airway Pressure (PAP) device 
chinstraps (A7036) and headgears (A7035). 
 
You asked the Plan to pre-approve 5 additional chinstraps and headgears. You say that you need to replace 
your accessories every month because you have developed a rash. The Plan denied your request. The Plan says 
this request exceeds the maximum amount allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that the usual maximum amount of accessories 
represented by codes A7035 and A7036 expected to be reasonable and necessary is 1 per 6 months. Quantities 
of supplies greater than those described in the policy as the usual maximum amounts will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The requested quantity of the items at issue exceeds the maximum 
allowed amount. Based on this information, we decided that Medicare rules for coverage of 5 additional 
chinstraps and headgears have not been met. Therefore, we decided that the Plan does not have to pre-approve 
5 additional positive airway Pressure (PAP) device chinstraps (A7036) and headgears (A7035).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from 
November 9, 2021, forward. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that the enrollee 
requires a structured environment and is unable to return home safely. The Plan denied your request. The Plan 
says under Medicare guidelines, the request is not medically necessary because the records received show your 
condition has improved and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a continued inpatient psychiatric 
admission. Our reviewer says that the continued inpatient psychiatric admission from November 9, 2021, 
forward is not medically necessary. Our physician reviewer found that you do not require inpatient mental 
health treatment beyond the dates in question as noted above as you were not a danger to yourself or others and 
do not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. It 
appears that the services were supervised and evaluated by a physician. Based upon review the records 
provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the 
date in question of November 9, 2021, forward and could have been treated in a lesser restrictive setting as you 
were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any 
aggressive behaviors while being cooperative and compliant. 
 
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 continued inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from November 
9, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from June 5, 2021, to July 3, 
2021 other than manual manipulation of the spine. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says while your concerns over the practices of this provider were escalated 
to the grievance department, the Plan contract is clear that services other than manual manipulation are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided from June 5, 2021, to July 3, 2021 other than manual manipulation of the spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-elastic binder for extremity with code A4465. 
 
You asked the Plan to pre-approve the compression garment. You say that you need this sleeve to reduce 
swelling. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A4465 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve the non-elastic 
binder for extremity with code A4465.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve compression stockings. You say that the requested items are a necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested items have not been met.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block (64454) provided April 12, 2021. 
 
You asked the Plan to pay for the genicular nerve block. You say that the procedure was medically necessary. 
The Plan denied your request. The Plan says this procedure is investigational and non-covered. 
 
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 pay for the genicular nerve block. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for a genicular nerve block (64454) provided April 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for air ambulance services you received on 
May 6, 2021. 
 
You asked the Plan to waive the copayment for the air ambulance services. You say that you were in the 
hospital for several hours after having a stroke when you were flown to another hospital for treatment.  You 
stated that you do not know why they flew you there if you were beyond the timeframe for treatment. The Plan 
denied your request. The Plan says you were charged this copayment 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 $500 
copayment for air ambulance services.  
 
You have been asked to pay a $500 copayment for the air ambulance services. This copayment applies 
regardless of the reason for the transport. 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 air 
ambulance services you received on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve laboratory services. You say that the provider you have requested is cleaner 
and more accessible than the in-network location you have been to. The Plan denied your request. The Plan 
says this is available 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 
laboratory services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you had on June 2, 2021.

You asked the Plan to waive the copayment for the TTE. You say that you are appealing this amount because the claim doesn't list the person or company who provided the service. The Plan denied your request. The Plan says you were charged this copayment 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 an $80 copayment for diagnostic procedures or tests in a doctor's office. 

You have been asked to pay an $80 copayment for the TTE. The TTE falls within the diagnostic procedures or tests in a doctor's office 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 transthoracic echocardiography (TTE) you had on June 2, 2021.