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

 
We decided that the Plan does not have to pay for the anesthesia services provided on October 25, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the anesthesia services. You say that services were provided to the enrollee and 
the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no in-network referral or services were not rendered in an in-network facility. 
Also, the services 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 anesthesia services provided on October 25, 
2021, 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 subsequent nursing facility care provided on August 2, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, 
emergent or approved in advance. 
 
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 subsequent nursing facility care provided on 
August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
August 21, 2021, to August 27, 2021. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you should not have to pay this 
amount because of the experience you had during this stay. The Plan denied your request. The Plan says the 
copayment amount you are being charged 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 $335 
copayment per day for days 1 to 6 and $0 copayment for additional days for each in-network inpatient stay. 
This inpatient stay lasted 6 days; however, you have only been asked to pay $1,675. 
 You have been asked to pay $1,675, which is less than $335 copayment per day for days 1 to 6 and $0 
copayment for additional days for inpatient stay. Inpatient stay falls within the Inpatient Hospital Care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from August 
21, 2021, to August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals. 
 
You asked the Plan to pre-approve home delivered meals. You say that you've had congestive heart failure for 
the last several years and your heart is not strong enough to remove the fluid from your lungs and body. You 
say that you wouldn't ask for help if you felt your balance was good enough to cook meals. The Plan denied 
your request. The Plan says your diagnosis is not congestive heart failure. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home delivered meals have not been met. Specifically, the records do not show you were admitted 
as an inpatient due to congestive heart failure. Therefore, we decided that the Plan does not have to pre-approve 
home delivered meals.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
11, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that your primary care physician 
told you to go to the urgent care center. The Plan denied your request. The Plan says the proper copayment was 
applied for this service. 
 
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 $35 
copayment for Urgent Care Center visit.  
 
  You have been asked to pay a $35 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently needed 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 an urgent 
care visit provided on November 11, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says when medically stable, you can be managed 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 you are not currently medically stable with very low hemoglobin and you do not 
need physician supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. You do not need intensive therapies, consisting of at least 3 
hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. 
You will not tolerate therapies with a hemoglobin of of 4.8. IRF admission is not medically necessary based on 
lack of medical stability and lack of acute rehab nursing needs. Your rehab needs can be met at a lower 
intensity setting once you are stable. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on August 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services 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 test at issue in this appeal, definitive drug testing, 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 the definitive drug testing rendered on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on August 23, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were informed that all COVID-
19 related treatment was fully covered. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for advanced imaging services, including CT scans.  
 
You have been asked to pay $148.29, which is less than the $225 copayment for the CT scan. Please note that 
COVID -19 cost share waivers ended on May 31, 2021. The CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a computed tomography (CT) scan of the thorax provided on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 14-day sensor 
 
You asked the Plan to pre-approve a freestyle libre 14-day sensor. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the member is only taken insulin once per a night and there is no 
documentation that the member is adjusting the insulin doses based on blood glucose results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a freestyle 
libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
freestyle libre 14-day sensor
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 this is medically necessary. The Plan 
denied your request. The Plan says the services needed could be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility, outpatient setting, or home care. 
 
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 was admitted with pulmonary infiltrates from COV-19 infection. The 
record indicates that the enrollee requires ongoing acute care services. The enrollee continues to receive acute 
care services and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not satisfied. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 29, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical services came to help you up off the floor after you fell. The Plan denied your request. The 
Plan says this claim processed correctly. 
 
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 September 29, 2021. 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 September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says LTACHs do not provide clinical advantage over a non LTACH acute care 
hospitals. 
 
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 you were admitted with acute hypoxic respiratory failure from COVID-19 
infection.  The record indicates that you still require high flow oxygen for oxygen desaturations and is not 
clinically stable. The record indicates that you require ongoing acute care services. You continue to receive 
acute care services and these have not been denied. The medical record does not indicate that you require 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not satisfied. 
 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 admission to a long term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says heart surgeons 
are available in 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 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 
cardiology services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on December 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you were never told this provider was an 
out-of-network provider. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no 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 outpatient services provided on December 23, 
2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services provided from July 15, 2021, to July 17, 2021.

You asked the Plan to waive the copayment for the ER services. You say that the entire hospital stay should be covered in full. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for each emergency room visit. Please note that coverage includes emergency medical care throughout the world. If you have an emergency outside the US and its territories, you will be responsible for paying for services rendered in advance. You must send proof of payment to the Plan for reimbursement. To get more information, see Chapter 7. We may not pay you back all of your out-of-pocket expenses. This is because our contracted rates may be lower than those of providers outside of the US and its territories. You are responsible for costs in excess the contracted rates, as well as all the shared costs of the corresponding affiliate.

You have been asked to pay $2,122.26 for the ER services. The file shows that the Plan has paid the maximum amount for the foreign hospital services. The ER services 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 emergency room (ER) services provided from July 15, 2021, to July 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator (BGS). 
 
You asked the Plan to pre-approve the ultrasonic BGS. You say that the enrollee's joint has not fused despite 
six-months since the fusion surgery. The Plan denied your request. The Plan says this is not covered out-of-
network. 
 
The Plan must follow Medicare rules. Medicare rules say that ultrasonic BGS is only covered when the criteria 
listed in the Medicare rules section are met. 
 
In this case, the enrollee does not have a fracture. The device is being requested for use for delayed fusion of a 
joint after fusion surgery. This is not one of the covered indications for an ultrasonic BGS. Therefore, we 
decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator (BGS).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635) 
and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or 
CT); lumbar or sacral, each additional facet joint (CPT code 64636). 
 
You asked the Plan to pre-approve the services. You say that the enrollee has had two (2) lumbar MBNB and 
had 70% pain relief. You state the enrollee will obtain longer and better pain relief with a left and right RFA. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee did 
not have greater than 80% relief from the original facet injections performed. 
 
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 services. Our physician reviewer 
found the LCD requires 80% pain relief from each set of diagnostic blocks. Since was not achieved, the request 
is deemed not medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635) and destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint (CPT code 64636).