Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need the utility benefits. The Plan denied 
your request. The Plan says based on the information submitted, there is no documentation that you meet the 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. 
Medical records were not provided for this case. The records show that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the required criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve 
special supplemental benefits for the chronically ill (SSBCI).
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 you are too weak to return home. You require 
contact guard assist and have minimum assist to stand and sit. The Plan denied your request. The Plan says the 
services you need could be provided safely in another setting. 
 
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 you are medically stable. There are no acute rehab nursing needs identified or 
documented. Documents do not support necessity for admission to an IRF. The complexity of your nursing, 
rehab, and medical, needs do not require an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitative care. While you may benefit from physical and occupational therapy, your needs can 
be provided in a lower intensity and alternate setting such as in-home with services. 
 
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 medical eye exam provided on August 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that the service should be covered under the 
authorization number that the facility received. The Plan denied your request. The Plan says the service was not 
authorized. 
 
 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 did not pre-approve the 
medical eye exam. We found no exception that would require the Plan to pay for the medical eye exam. 
Therefore, we decided that the Plan does not have to pay for the medical eye exam provided on August 9, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were informed that the provider took your 
insurance at the appointment. The Plan denied your request. The Plan says the service was not authorized. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on September 21, 2022, 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 if the enrollee does not admit to the acute patient 
rehab level, they risk further respiratory de-compensation. They are at risk for fall and possible injury due to 
orthostasis and the enrollee would be at high risk for readmission to the hospital. The Plan denied your request. 
The Plan says the services the enrollee needs can be provided safely in another setting such as a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 the enrollee is medically stable. The documents do not support necessity for 
admission to an IRF. The complexity of the enrollee's nursing, and medical needs do not require an acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. While the enrollee may 
benefit from physical and occupational therapy, the enrollee's rehab needs can be provided in a lower intensity 
and alternate setting such as in 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute psychiatric hospitalization provided on October 7, 
2022, to October 11, 2022. 
 
You asked the Plan to pay for an acute psychiatric hospitalization. You say that the enrollee needed these 
services due to chemical dependency. The Plan denied your request. The Plan says an inpatient admission was 
not medically necessary. 
 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 pay for an acute psychiatric hospitalization. Our 
reviewer says that an inpatient admission was not medically necessary. Our physician reviewer found it did not 
appear that the services were reasonably expected to improve the enrollees condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an acute psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pay for an acute psychiatric hospitalization provided on October 7, 2022, to 
October 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery services provided on October 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient surgery services. You say that the provider should be paid for the 
service that was performed. You also say that there was no authorization required for the outpatient services. 
The Plan denied your request. The Plan says this service was rendered by an OON supplier which requires 
authorization and there is not one on file. 
 
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 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 outpatient surgery services provided on 
October 12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam, the fundus photography, and the 
refraction provided on September 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you are a participating provider with the Plan. 
The Plan denied your request. The Plan says the provider was out-of-network, and the enrollee was not referred 
by their primary care physician. 
 
 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 did not pre-approve the 
vision services. We found no exception that would require the Plan to pay for the vision services. Therefore, we 
decided that the Plan does not have to pay for the medical eye exam, the fundus photography, and the refraction 
provided on September 7, 2022, 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 has multiple broken bones and was in 
the hospital. The doctors said their sodium was low too. They have pain but are willing to participate in 
therapy. The Plan denied your request. The Plan says the services the enrollee needs can be provided safely in 
another setting such as a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
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 the enrollee is medically stable. The enrollee needs routine physical and occupational 
therapy but does not need intensive therapies. The enrollee's rehab needs can be provided in a lower intensity 
and alternate setting such 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: Partially Favorable

 
We decided that the Plan has to waive the copayment for the methylprednisolone acetate injection provided on 
December 2, 2022. We also decided that the Plan does not have to waive the copayment for the arthrocentesis 
provided on December 2, 2022.  
 
You asked the Plan to waive the copayments for the arthrocentesis and methylprednisolone acetate injection. 
You say that you are being charged twice for the same procedure. The Plan says that this cost sharing was 
charged correctly. 
 
 We decided that the Plan has to waive the copayment for the injection.  
 
You have been asked to pay a $15 copayment for the methylprednisolone acetate injection. According to 
Medicare, the methylprednisolone acetate injection (J1030) that assessed a cost share amount is considered a 
packaged code and is not separately payable. This code is also excluded from the physicians free schedule. 
Therefore, we decided that the Plan has to waive the copayment for the injection provided on December 2, 
2022. 
 
We also decided that the Plan does not have to waive the copayment for the arthrocentesis. 
 
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 $15 
copayment for specialist physician/practitioner services.  
 
You have been asked to pay a $15 copayment for the arthrocentesis. This item/service falls within the 
physician/practitioner 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 
the arthrocentesis provided on December 2, 2022. 
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you received a letter stating you do not 
qualify for SSBCI services. The Plan denied your request. The Plan says that based on the information 
submitted there is no documentation that you meet all 3 criteria. 
 
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. Specifically, the records do not support that the Plan made multiple attempts to 
obtain medical records from the provider for this case. The records also show that an attestation from the 
provider was sent to the Plan, but this attestation was not submitted with this case. This means that the Plan has 
not provided a valid reason for denying payment of the SSBCI benefits. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of chest with contrast, a CT scan of abdomen and 
pelvis with contrast, low osmolar contrast material, and routine venipuncture provided on August 1, 2022, by 
an OON provider. 
 
You asked the Plan to pay for a CT scan of the chest, a CT scan of the abdomen and pelvis, low osmolar 
contrast material, and routine venipuncture. You say that you are appealing this denial based on medical 
necessity. The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a CT scan of chest with contrast, a CT scan of the 
abdomen and pelvis with contrast, low osmolar contrast material, and routine venipuncture provided on  
August 1, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided in the Socialist Republic of Vietnam 
on May 23, 2022. 
 
You asked the Plan to pay for dental services. You say that you cannot find where the Plan policy states that 
your dental benefit cannot be used for out-of-country dental expenses. The Plan denied your request. The Plan 
says non-emergency dental services are not covered when performed outside of the United States. 
 
The Plan must follow Medicare rules. Medicare rules say that items/services furnished outside of the United 
States and its territories are only covered under certain, specified circumstances. The Plan offers worldwide 
coverage that goes beyond Medicares coverage. For that reason, the Plans rules apply to this case. The Plan 
covers worldwide emergency care and emergency ground ambulance transportation. 
 
We looked at the file and Medicare rules. These dental services do not fall within any of Medicares coverage 
conditions for items/services furnished outside of the United States and its territories. Additionally, these 
services are not covered by the Plans worldwide coverage benefits because they were not emergency care. 
Based on this information, we decided that Medicare rules for coverage of dental services have not been met. 
Therefore, we decided that the Plan does not have to pay for dental services provided in the Socialist Republic 
of Vietnam on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on November 11, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you went through the right procedures to get 
hearing aids and paid out-of-pocket. The Plan denied your request. The Plan says the service was not a covered 
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 only when received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on May 5, 2022, and 
July 18, 2022. We also decided the Plan does not have to waive the copayment for an MRI of the neck 
provided on November 5, 2022. 
 
You asked the Plan to waive the copayment for injections and an MRI. You say that you only have your 
pension, and it is not enough to cover all of your medical bills. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $250 per 
day for an injection. Your contract with the Plan also clearly says that you must pay a $250 copayment per day 
for an MRI.  You have been asked to pay $750 ($250/injection x 2 injections = $500; $250/MRI; $500 + $250= $750). The 
injections fall within the outpatient procedures and services benefit category. The MRI falls within the 
diagnostic radiology services that are not ultrasounds 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 injections provided on May 5, 2022, and July 18, 2022, or MRI of the neck provided on 
November 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the criteria for an 
LTACH appropriate admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in 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 the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended. 
 
 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 LTACH services.