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

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the cataract surgery. You say that you prefer to see another out-of-network 
provider in the same clinic as the provider who rendered your urgent eye surgery in November 2021. The Plan 
denied your request. The Plan says services to an out-of-network provider are only approved at the enrollee's 
in-network benefit level when the service is not available through the Plan's provider network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the cataract surgery. We found no exception that would require the Plan to pre-
approve the cataract surgery. The records provided for review do not show that the cataract surgery is urgent or 
emergent. Therefore, we decided that the Plan does not have to pre-approve cataract surgery to be provided by 
an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide (HHA) (S9122) provided on February 
28, 2022. 
 
You asked the Plan to pay for the HHA. You say that you would like to be reimbursed a 50% coinsurance 
according to the Plan benefit coverage for this service. The Plan denied your request. The Plan says this service 
was rendered by a provider who is not under contract with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the HHA have not been met. This provider is not part of the Medicare program and is not payable. 
Therefore, we decided that the Plan does not have to pay for the home health aide (HHA) (S9122) provided on 
February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on March 4, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that since this was a telehealth visit 
and only lasted a few seconds it should be covered. The Plan denied your request. The Plan says the copayment 
applied 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 specialist telehealth visit.  
 
You have been asked to pay $30 copayment for telehealth visit. Telehealth visits fall within the 
Physician/Practitioner Services, Including Doctor's Office 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 telehealth visit provided on March 4, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not completed inpatient 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 the enrollee is not medically stable, and needs acute hospital care, not physician 
supervision three times a week (at a minimum), for the ongoing management of any active or acute exacerbations of chronic medical conditions. There were no acute rehab or nursing needs identified or 
documented. At the enrollee's current functional level, intensive therapies are not needed, consisting of at least 
three hours a day of therapy, at least five days per week, with a multidisciplinary approach. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that it's too early to discharge the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements. 
 
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 SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found the enrollee does 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97810 x 4, 97811 x 8) provided 
from October 13, 2021, to October 22, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that the services should be covered. The Plan 
denied your request. The Plan says these services are not covered when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments. The rules also say that auxiliary personnel furnishing acupuncture must be under the appropriate 
level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record shows that the enrollee was treated by a 
licensed acupuncturist. Additionally, a licensed chiropractor directed the care given to the enrollee. Therefore, 
we decided that the Plan does not have to pay for the acupuncture services (97810 x 4, 97811 x 8) provided 
from October 13, 2021, to October 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you were there for over eight hours, and 
you never received any treatment. The Plan denied your request. The Plan says the copayment applied 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 $85 
copayment for each visit to an emergency room.  
 
You have been asked to pay $85 copayment for ER visit. ER visits fall 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. Therefore, we 
decided that the Plan does not have to waive the copayment for ER visit provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office consultation and follow-up visit to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office consultation and follow-up visit. You say that you have several 
bad brain problems, and the out-of-network clinic is one of the best clinics in the world. You say you were 
unaware the facility is out-of-network. The Plan denied your request. The Plan says the provider is out-of-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the office consultation and follow-up visit. We found no exception that would 
require the Plan to pre-approve the office consultation and follow-up visit. The records provided for review do 
not show that the office consultation and follow-up visit are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the office consultation and follow-up visit 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 pay for the ambulance response and treatment with no transport 
(A0998) provided on February 20, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not call the police or the ambulance, did not use any of their services, and feel you should not be held 
responsible. The Plan denied your request. The Plan says the allowed amount is less than the copay amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 20, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on February 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS implant device. 
 
You asked the Plan to pre-approve a CardioMEMS implant device. You say that this is medically necessary. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
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 a CardioMEMS implant device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that at issue is the medical appropriateness and necessity of implantation of 
the wireless pulmonary artery pressure monitoring system CardioMEMS for management of congestive heart 
failure in this patient. The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 
2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery 
pressure in the management of patients with congestive heart failure. The clinical study on which FDA 
approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS implant device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CardioMEMS implant device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear (codes V2750, V2781, V2784, V2797, and 
V2020) provided on February 24, 2022. 
 You asked the Plan to pay for the eyewear. You say that you required new glasses after an extensive procedure. 
You also say that your old glasses did not work and were painful to wear. The Plan denied your request. The 
Plan says these glasses exceed the maximum benefit per period. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 pair of standard lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. The record shows that payment was issued for 1 pair of glasses 
provided on February 9, 2021, and your routine eyewear benefit has been exhausted. Based on this information, 
we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the 
Plan does not have to pay for the eyewear (codes V2750, V2781, V2784, V2797, and V2020) provided on 
February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positive airway pressure filter, tubing, and the 
replacement mask provided on October 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the positive airway pressure filter, tubing, and the replacement mask. You say 
that the equipment was medically necessary. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 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 
positive airway pressure filter, tubing, and the replacement mask. We found no exception that would require 
the Plan to pay for the positive airway pressure filter, tubing, and the replacement mask. The records provided 
for review do not show that the positive airway pressure filter, tubing, and the replacement mask were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the positive airway pressure filter, 
tubing, and the replacement mask provided on October 20, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology office visit. You say that you have a serious eye 
condition that an ophthalmologist has been taking care of for years. You say you do not feel comfortable with 
going to another doctor. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the ophthalmology office visit. We found no exception that would require the Plan 
to pre-approve the ophthalmology office visit. The records provided for review do not show that the 
ophthalmology visit is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve 
the ophthalmology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve epidural. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because the enrollee previously had 
an epidural on May 3, 2022 and the record does not show that it failed. 
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injections may be covered if 
the prior injection provided at least 50% improvement in pain relief and/or function for at least 3 months. 
 
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 epidural. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested epidural. Our physician reviewer found Medicare 
requires at least 50% pain relief for 3 months following the previous epidural procedure, which has not been 
achieved yet. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for specialist office visit provided on January 5, 
2022. 
 
You asked the Plan to waive the cost share for specialist office visit. You say that you shouldn't be charged a 
deductible and a copayment at the same time. The Plan denied your request. The Plan says the cost share 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $100 deductible which applies to specialist office visits and a $25 
copayment for specialist office visits.  
 
 
 The item or service you asked the Plan to waive the cost share for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $100 deductible which applies to specialist office visits. This 
cost sharing is a contractual obligation that had not been met at the time specialist office visit was received on 
January 5, 2022. Therefore, $100 has been applied to meet the deductible.  
 
Since the $100 deductible was met, you have also been asked to pay $20 copayment which is less than the 
standard $25 copayment for specialist office visit 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 the Plan does not have to waive the cost for specialist 
office visit provided on January 5, 2022.
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 provider feels the enrollee's health and recovery 
will be adversely affected if required to wait the standard timeframe. The Plan denied your request. The Plan 
says the records received do not support IRF. 
 
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 does not require frequent physiatry oversight. Our physician reviewer also found that the enrollee does not have medical needs which require management in 
an acute rehabilitation hospital in order to participate in a rehabilitation program. 
 
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.