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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on August 24, 2021 and August 30, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-
network (OON) provider on August 24, 2021 and August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy provided on October 28, 2021. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you cannot afford to pay this bill 
because you are on a fixed income. The Plan denied your request. The Plan says copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $175 
copayment for Medicare-covered surgery services at an in-network ambulatory surgical center.  
 
You have been asked to pay $175 copayment for endoscopy. The endoscopy falls within the Outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for endoscopy provided 
on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab and Talimogene Laherparepvec. 
 
You asked the Plan to pre-approve Pembrolizumab and Talimogene Laherparepvec. You say that this drug 
combination is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says 
these drugs are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pembrolizumab and Talimogene 
Laherparepvec. Our reviewer says that the requested drugs are not medically reasonable and necessary. Our 
physician reviewer found the requested use of Pembrolizumab and Talimogene Laherparepvec is not FDA-
approved for the enrollee's diagnosis. The documentation is insufficient to demonstrate that the enrollee in this 
case has stage IIB, IIC, or III disease following complete resection, or unresectable/metastatic melanoma. The 
documentation does not support that the enrollee has recurrent melanoma with cutaneous, subcutaneous and 
nodal lesions following initial surgery. In addition, the requested use of these drugs is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab and Talimogene Laherparepvec have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Pembrolizumab and Talimogene Laherparepvec.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic services provided on January 18, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the orthopedic services. You say that it was medically necessary to treat the 
enrollee and you would like the claim reprocessed. 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 orthopedic services provided on January 18, 
2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) admission. 
 
You asked the Plan to pay for the LTACH admission. You say that the services are medically necessary. You 
say that the admission is considered high risk and critical to the enrollee's health and ability in function. You 
say that the provider advised rehabilitation is not an available option due to the enrollee's health conditions. 
The Plan denied your request. The Plan says the requested admission 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 pay for the LTACH admission. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. Therefore, the 
requested LTACH service 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 admission have not been met. Therefore, we decided that the Plan 
does not have to pay for long term acute care hospital (LTACH) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that this care is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available 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 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 medical 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from IRF care to 
optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says criteria 
for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs 
can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eighty (80) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips to get to your dialysis appointments three times a week. You are wheelchair bound, your 
son lives out of town, and you do not have any friends with cars. The Plan denied your request. The Plan says 
you have exhausted your 2022 benefit for routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve eighty (80) additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the sacroiliac joint injection with imaging 
guidance provided on August 25, 2021. 
 
You asked the Plan to waive the copayment for sacroiliac joint injection with imaging guidance. You say that 
you should not be charged a copayment since this procedure did not constitute an office visit. The Plan denied 
your request. The Plan says copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, 
and urgently needed services). 
 You have been asked to pay $30 copayment for sacroiliac joint injection with imaging guidance. The sacroiliac 
joint injection with imaging guidance falls within the Physician/ Practitioner services, including doctor's 
visits benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the sacroiliac joint injection with 
imaging guidance provided on August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of neurostimulator system for treatment of 
central sleep apnea. 
 
You asked the Plan to pre-approve insertion of neurostimulator system for treatment of central sleep apnea. 
You say that this item is medically necessary. The Plan denied your request. The Plan says the current evidence 
regarding this device is insufficient and requires additional research. 
 
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 insertion of neurostimulator system for 
treatment of central sleep apnea. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the patient is a 71-year-old male 
with primary central sleep apnea. A request was made for insertion of neurostimulator system for treatment of 
central sleep apnea. Although there is some limited data with small groups of individuals having tried phrenic 
nerve stimulation to treat sleep apnea, currently available studies are insufficient to more completely evaluate 
long-term risk and effectiveness beyond 5 years. Also, it was not clear from the provided documentation which 
treatments had been tried for this patient's sleep apnea. Therefore, this request for neurostimulator system will be considered not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of neurostimulator system for treatment of central sleep apnea have 
not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of neurostimulator 
system for treatment of central sleep apnea.
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is status post right total 
knee arthroplasty (TKA). From a nursing perspective, the enrollee received oral medications.  The enrollee had 
stable vital signs. His lungs were clear. He was treated for pain. Regarding rehabilitation services, the enrollee 
received physical therapy and occupational therapy. The enrollee was at a supervision level for functional 
mobility including gait to 50 feet. The enrollee required varying assist with activities of daily living. 
 
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. 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 admission to a SNF 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injections provided on September 15, 
2020, and September 30, 2020. 
 
You asked the Plan to waive the copayment for the injections. You say that you have been sent the bill multiple 
times and you cannot figure out what you owe. The Plan denied your request. The Plan says the proper 
coinsurance was applied for the service that was billed from the provider. 
  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 20% 
coinsurance for each Medicare-covered Part B drug. Additionally, for the administration of that drug, you will 
pay the cost-sharing that applies to primary care provider services, specialist services, or outpatient hospital 
services. On September 15, 2020, the total amount allowed was $6,198 with a coinsurance of $1,239.60 
($6,198 total amount allowed x 20% coinsurance). On September 30, 2020, the total amount allowed was 
$6,198 with only $210.69 being charged as the coinsurance because the annual maximum-out-of-pocket was 
met during the date of service. The normal coinsurance amount would have been $1,239.60 ($6,198 total 
amount allowed x 20% coinsurance). The total amount of coinsurance charged for both dates of service was 
$1,450.29 ($1,239.60 coinsurance + $210.69 coinsurance). 
 
You have been asked to pay a $1,450.29 coinsurance for the injections. The injections fall within the Medicare 
Part B Prescription Drugs 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 
injections provided on September 15, 2020, and September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided by on November 
17, 2021, November 22, 2021, November 24, 2021, November 29, 2021, December 1, 2021, December 6, 
2021, December 8, 2021, December 13, 2021, December 15, 2021, and December 20, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were informed that you were 
going to pay less, and the provider never told you about the coinsurance charge. The Plan denied your request. 
The Plan says they waived the specialist copayment for each date and the proper coinsurance was applied for 
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 20% 
coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs. The 
total amount allowed for each date of service was $454.86 with a coinsurance of $90.97 ($454.86 total amount 
allowed x 20% coinsurance). There was a total of 10 dates of service the total coinsurance amount was $909.70 
($90.97 coinsurance each date x 10 dates). 
 
You have been asked to pay a $909.70 coinsurance for the injections. The injections falls within Medicare Part 
B Prescription Drugs 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 coinsurance for the 
injections provided by on November 17, 2021, November 22, 2021, November 24, 2021, November 29, 2021, 
December 1, 2021, December 6, 2021, December 8, 2021, December 13, 2021, December 15, 2021, and 
December 20, 2021.
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 the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee is ambulating 100 feet and tending to ADLs 
with minimal supervision. Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided at a lower level of 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the porcelain crown (D2750). 
 
You asked the Plan to pre-approve the porcelain crown. You say that the service is medically necessary. The 
Plan denied your request. The Plan says you have exhausted the Plan benefit for this service. 
 
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 the 
porcelain crown (D2750).