Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Online Digital Evaluation and Management services 
provided on September 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Online Digital Evaluation and Management services. You say that you would 
like to request reconsideration for payment. 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 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 Online Digital Evaluation and Management 
services provided on September 16, 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 lift and tilt positioning system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is not primarily used to take care of a medical need. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that a lift and tilt power positioning system was requested. The item at issue in this appeal does 
not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to 
pre-approve a lift and tilt positioning system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
June 11, 2021, to June 16, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that there are discrepancies 
shown on your hospital statements and the claim summaries for July and November 2021. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per day for days 1-6 for an in-network inpatient hospital stay. The contract also says that there is a 
$0 copayment for additional days after day 6.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,475, which is a $295 copayment per day for a five-day inpatient hospital stay ($295 copayment x 5 
days = $1,475). There is no charge for the day of discharge. 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 an inpatient hospital stay 
provided from June 11, 2021, to June 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on June 7, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the physician services. You say that the services rendered to the enrollee was out 
of medical necessity 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 physician services provided on June 7, 2021, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hospital services provided on December 14, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Hospital services. You say that you would like to request reconsideration for 
payment. 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 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 Hospital services provided on December 14, 2021 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy with direct vision internal urethrotomy 
(52276) rendered by the out-of-network (OON) provider on January 4, 2022. 
 
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 cystourethroscopy with direct vision internal urethrotomy (52276) rendered by the 
out-of-network (OON) provider on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral formula and feeding supply kit. 
 
You asked the Plan to pre-approve enteral formula and feeding supply kit. You say that this is medically 
reasonable and necessary based on the enrollee's condition. The Plan denied your request. The Plan says the 
member has functioning gastrointestinal tract whose need for enteral nutrition is not due to reasons related to 
the non-function or disease of the structures that normally permit food to reach the small bowel. 
 
The Plan follows Medicare rules. Medicare rules say that enteral nutrition is subject to the criteria listed 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 enteral formula and feeding supply kit. 
Our reviewer says that the requested medical services are not medically reasonable and necessary. Our 
physician reviewer found the reviewed documentation indicates that the enrollee is status post PEG Tube 
Placement, failure to thrive, has not been eating well for several months. Tolerating PEG Tube and Formulated 
Nutrition.  He is also tolerating oral diet. Recent hospitalization in March 2022, for shortness of breath, and non-displaced 
right superior pubic ramus fracture. X-ray services showed congestive heart failure. The enrollee's provider 
requested feeding tube supplies for the member on March 16, 2022. The request was denied as member has 
functioning gastrointestinal tract whose need for enteral nutrition is not due to reasons related to the non-
function or disease of the structures that normally permit food to reach the small bowel. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enteral formula and feeding supply kit have not been met. Therefore, we 
decided that the Plan does not have to pre-approve enteral formula and feeding supply kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you were advised prior to enrolling with the Plan that you would be able to continue 
receiving services with this provider. The Plan denied your request. The Plan says routine monitoring with 
pacemaker check and cardiovascular follow-up can be safely performed 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 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 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (implanted heart monitor). 
 
You asked the Plan to pre-approve the insertion, subcutaneous cardiac rhythm monitor, including programming 
(implanted heart monitor). You say that the service is medically necessary. The Plan denied your request. The 
Plan says based on the clinical information provided to us, the member has not had any syncopal episodes 
(have not passed out). 
 
The Plan follows Medicare rules. Medicare rules say that an Implantable (or Insertable Loop) Recorder (ILR) is 
used when syncope is thought to be cardiac-related, but is too infrequent to be detected by either a HolterTM 
monitor or a traditional pre-symptom MLR. 
 
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 insertion, subcutaneous cardiac 
rhythm monitor, including programming (implanted heart monitor). Our reviewer says that the service is not 
medically necessary. Our physician reviewer found there is no documentation provided to suggest a history of 
unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. 
 
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 insertion, subcutaneous cardiac rhythm monitor, including programming 
(implanted heart monitor) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the insertion, subcutaneous cardiac rhythm monitor, including programming (implanted heart monitor).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on December 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to request reconsideration for 
payment. 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 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 Laboratory services provided on December 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 30, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you paid a $10 copayment on the 
date of the office visit but received a statement from a consulting firm indicating you owe and additional $10. 
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). The health plan contract says that enrollees must pay a $20 
copayment for services obtained from a specialist. 
 
You have been asked to pay a total copayment of $20 for the office visit. An office visit falls within the 
Physician/Practitioner Services benefit category. The records show you already paid $10 and only owe an 
additional $10. 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 office visit provided on November 30, 
2021.
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 needs rehabilitation. The Plan denied 
your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 that there are no rehab nursing needs identified or documented in the record. You are 
medically stable and do not require physician supervision 3 times per week for the ongoing management of any 
active or acute exacerbations of chronic medical conditions.  Your rehab needs can be met in an alternate and lower setting such as a skilled nursing facility.  
 
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 pay for the physician services provided on December 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services rendered was medically 
necessary and you would like the claim reprocessed 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 the physician services provided on December 7, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Sensipar tablet. 
 
You asked the Plan to pre-approve Sensipar. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Sensipar 
tablet.  
 Benefits for Sensipar may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the SNF admission. You say that you have been in the hospital in ICU for 3 
weeks and you need to be put in rehab center. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 skilled nursing facility (SNF) admission to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth services (D7240). 
 
You asked the Plan to pre-approve removal of impacted tooth services. You say that this dental care is 
medically necessary. The Plan denied your request. The Plan says this specific dental service is not covered 
under the enrollee's supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of impacted tooth services (D7240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH level of 
care in order to fully recover. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
in-patient acute care and does not require transfer to an LTACH. 
 
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.