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

 
We decided that the Plan does not have to pay for lab testing provided on November 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that these services were referred by the enrollee's physician. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
provider is out-of-network with the Plan and the ordering physician was also out-of-network with the 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 lab testing provided on November 29, 2021 by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the ER visit and self-administered drugs provided 
from December 17, 2021, through December 18, 2021. 
 
You asked the Plan to waive the cost for the ER visit and self-administered drugs. You say that the cost of the 
emergency visit should have been full covered. The Plan denied your request. The Plan says the copayment 
applied correctly, and self-administered drugs are not covered by Medicare Part B. 
 
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 services in an emergency room. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency 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. In 
addition, the rules say that Medicare Part B generally does not pay for self-administered drugs. The self-
administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, 
we decided that the Plan does not have to waive the cost for the ER visit and self-administered drugs provided 
from December 17, 2021, through December 18, 2021.  
 
Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lipid panel testing (80061) hemoglobin (83036) thyroid 
stimulating hormone (84443) provided November 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you believe that the services should be 
covered by the Plan. The Plan denied your request. The Plan says lab or diagnostic tests for screening purposes 
performed in the absence of signs, symptoms or complaints are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal, was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lipid panel testing 
(80061) hemoglobin (83036) thyroid stimulating hormone (84443) provided November 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol. 
 
You asked the Plan to pre-approve Tramadol. The Plan denied your request. The Plan says Tramadol to be 
administered at home is not covered under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tramadol.  
 
 
 Benefits for Tramadol 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you feel confident with this provider 
performing this surgery. The Plan denied your request. The Plan says there are in-network providers that can 
provide this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to 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 most appropriate level of 
care. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on 
December 14, 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 service 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 each urgent care visit.  
 
You have been asked to pay a $40 copayment for the urgent care office visit 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 copayment for the office visit (99213) provided on  
December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from July 1, 2019, to July 30, 
2019. 
 
You asked the Plan to pay for the medical services. You say that these services were provided to the enrollee in 
good faith. The Plan denied your request. The Plan says you have 365 days from the date on the explanation of 
payment to submit a corrected claim. The Plan also says that the explanation of payment for this claim was sent 
on June 10, 2020, and the corrected claim was received on October 11, 2021. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 
 
 The record shows that a claim for the medical services was not filed until October 11, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the medical services provided from July 1, 2019, to July 30, 
2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional home health physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for a skilled physical therapist to make 
more home visits at this time. 
 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 additional visits. Our reviewer says 
that the requested visits are not medically reasonable or necessary. Our physician reviewer found there are no 
documented ongoing home health physical therapy needs. You are functioning at a level commensurate with a 
lower level of care, such as a home exercise program and outpatient therapy. As such the requested ongoing 
services are not medically reasonable or 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five additional home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hearing aid for your right ear. 
 
You asked the Plan to pre-approve a hearing aid. You say that this hearing aid is medically necessary, and you 
have lost significant hearing in your right ear. The Plan denied your request. The Plan says you previously used 
your hearing aid benefit on November 29, 2021, which is less than two years before this request. The request 
for a second hearing aid exceeds the frequency limitations of your benefit. 
 
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 up to $1,500 once every two years for both ears combined.  
 
We looked at the file and the Plan's rules. Documentation shows that you used your hearing aid benefit less 
than two years before this request. Based on this information, we decided that the Plan's rules for coverage of a 
hearing aid have not been met. Therefore, we decided that the Plan does not have to pre-approve a hearing aid 
for your right ear.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve continued services. You say that the enrollee is a potential threat to himself 
and others. The Plan denied your request. The Plan says that medical records were not provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. Medicare rules say that a contract provider is an agent of the plan. It is the 
Plans obligation to provide those records, or at the very least, show clearly that they were unsuccessful in 
getting the records after multiple tries. There is no documentation, such as fax or phone call transcripts to show 
that the Plan made multiple attempts to obtain additional information. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pre-approve continued inpatient mental health services.  
 
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: Partially Favorable

 
We decided that the Plan has to reduce the $69.84 coinsurance for the injection. We also decided that the Plan 
does not have to waive the coinsurance for $59.36.  
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not informed or aware 
you had a copay for the injection and that you would have declined the injection if you had known. The Plan 
says that the coinsurance applied is correct. 
 
 We decided that the Plan has to reduce the $69.84 coinsurance for the injection.  
 
The Plan follows Medicare rules. Medicare rules say that there is a 15% coinsurance for Medicare Part B 
Prescription Drugs. The allowed amount of the injection was $395.76, and 15% of this is not $69.84. 
Therefore, we decided that the Plan has to reduce the $69.84 coinsurance for the injection.  
 
We also decided that the Plan does not have to waive the coinsurance for $59.36. 
 
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% 
coinsurance for the injection. Therefore, we decided that the Plan does not have to waive the coinsurance for 
$59.36. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary due to weakness and 
low endurance. The Plan denied your request. The Plan says you are near your maximum rehabilitation 
potential. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that you require skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. There is no 
documentation that further daily skilled services are required. Although the records document some 
improvement with the therapy you were receiving in January and February 2022, the trajectory of your 
improvement did not appear to be predictable for recovery in a reasonable timeframe to necessitate continued 
daily therapy. Part time therapy in the long term care facility appeared indicated. Services in the long-term care 
facility on a part time basis appear appropriate in this case. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
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 SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you are walking household distances with 
supervision and is supervision level for transfers. Provided records do not document a significant decline in 
your functional status to necessitate daily inpatient skilled therapy services. You do not require the services on 
an inpatient basis, only in a skilled nursing facility setting. Provided records are inadequate to document why 
continued services in the home with home health care are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ROMTech Portable Connect device. 
 
You asked the Plan to pre-approve ROMTech Portable Connect. You say that a home unit as part of the 
enrollee's treatment protocol will facilitate a quicker return to functional restoration. The Plan denied your 
request. The Plan says the denial of authorization for this item is correct, because a ROMTech Portable 
Connect device is not primarily medical in nature and is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a ROMTech Portable Connect device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on November 12, 
2021. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not document a discussion of a need for the supplies provided in 
this case. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on 
November 12, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services coded 80307, 83789 and G0480 provided on 
July 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says that this claim has not been billed with an 
appropriate place of service code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment citing the billed place of service code 
being incorrectly coded as 81. However, the place of service code for this claim is clearly marked as 11 on the 
claim form. As a result, the Plan has failed to substantiate their denial. Therefore, we decided that the Plan has 
to pay for the laboratory services coded 80307, 83789 and G0480 provided on July 22, 2021.  
 
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.