Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. The procedure can be performed at 
observational level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is a 79-year-old female with paroxysmal atrial fibrillation and 
heart block with pacemaker who is planning on getting the Watchman procedure. This is a request for inpatient 
services following this procedure. However, this procedure is typically ambulatory or completed at an 
observation level of care and there was insufficient evidence from recent documentation of the enrollee having 
a complex or high-risk clinical situation to warrant a higher level of care following this procedure. It is not 
expected that the enrollee will require hospital services that will likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 unable to care for yourself and have no one 
at home to help. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not 
been met. 
 
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 functioning at a home care level and your pace of improvement indicates you 
do not require intensive rehabilitation 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 waive the cost share for out-of-network injection provided on 
February 12, 2020. 
 
You asked the Plan to waive the cost share for out-of-network injection. You say that you disagree with the 
cost share. 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. Your 
contract with the Plan says that there is 45% coinsurance and a $1000 deductible which applies to out-of-
network Medicare Part B prescription drugs.  
 
The item or service you asked the Plan to waive the cost share for falls within the out-of-network Medicare Part 
B prescription drugs benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is 45% coinsurance and a $1000 deductible which applies to out-of-network Medicare Part B 
prescription drugs. You are being asked to pay $509.26 towards your deductible. The remaining balance of the 
injection is $246.03. However, you are only being asked to pay 20% for one injection which is less than the 
required amount, the total allowed amount for one injection is $1,056. You are being asked to pay $211.20 ($1,056 x 20% =$211.20). The total amount you are being asked to pay is $966.49 ($509.26 + $246.03 + 
$211.20 =$966.49). This cost sharing is a contractual obligation that had not been met at the time out-of-
network injection was received on February 12, 2020. Therefore, we decided that the Plan does not have to 
waive the cost share for out-of-network injection provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP device and humidifier provided 
from October 5, 2022, to November 5, 2022. 
 
You asked the Plan to waive the coinsurance for the CPAP and humidifier. You say that you were told it would 
be covered in full if medically necessary. 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 20% 
coinsurance for Medicare-covered durable medical equipment.  
 
 You have been asked to pay 20% coinsurance for the CPAP and humidifier. This item/service falls within the 
durable medical equipment and related supplies benefit category.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
October 5, 2022 CPAP $225.61 $45.12 
October 5, 2022 Humidifier $11.84 $2.37 
November 5, 2022 CPAP $225.61 $45.12 
November 5, 2022 Humidifier $11.84 $2.37 
 
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 continuous positive airway pressure (CPAP) device and 
humidifier provided from October 5, 2022, to November 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on September 20, 2022. 
 
You asked the Plan to pay for a telehealth visit. You say that this patient was housebound due to covid and was 
unable to see an in-network provider. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telehealth visit 
provided on September 20, 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's needs rehab to regain their 
maximum level of function. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary, and the enrollee's needs can be met in another setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that proton therapy is medically necessary for 
the enrollee's treatment. The Plan denied your request. The Plan says this 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling data to suggest that proton therapy is superior to - or more 
beneficiary than - intensity-modulated radiation therapy (IMRT)/image-guided radiation therapy (IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials 
and to not routinely offer it to patients. While guidelines consider proton therapy a reasonable alternative they do not describe it as being necessary in lieu of non-proton based treatment and are quite clear that there is no 
evidence of its superiority. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on November 22, 2022. 
 You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says services 
would be covered under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on November 22, 2022.
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 the enrollee has completed their acute 
care course and will be best managed at the LTACH at this time. The Plan denied your request. The Plan says 
continued acute hospital stay was offered, until the enrollee could discharge to a lower level. 
 
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 record indicates that the enrollee is improving but still has ongoing acute medical 
issues and requires acute care services before transitioning to a lower level of care. 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 they are 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2740), core buildup (D2950), a pontic (D6245), 
and retainer crowns (D6740) for tooth #6, #7, #8, #9, #10, and #11 provided on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services provided were preventative 
services and your coverage includes preventative services. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because crowns, core buildup, pontics, and retainer crowns are 
not covered by the Plan. 
 
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 pay for crowns 
(D2740), core buildup (D2950), a pontic (D6245), and retainer crowns (D6740) for tooth #6, #7, #8, #9, #10, 
and #11 provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring services provided on May 30, 
2022. 
 
You asked the Plan to pay for remote physiologic monitoring services. You say that this was medically 
necessary and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote physiologic 
monitoring services provided on May 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 90 additional routine transportation miles, for a total of 
140 miles each way. 
 
  You asked the Plan to pre-approve the additional miles. You say that you do not have any other mode of 
transportation to or from your neurology appointments. The Plan denied your request. The Plan says you are 
requesting an additional 90 miles for a total of 140 miles. The Plan also says this request is not approved 
because your benefit only allows 50 miles. 
 
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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 90 additional routine transportation miles, for a total of 140 miles each way.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no evidence proton beam therapy is beneficial for the enrollee's condition. 
 
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 the requested services. Our physician 
reviewer found that proton therapy is not an accepted standard for the palliative treatment of metastatic disease. 
There are no consensus guidelines or literature provided to support the need for proton therapy in this enrollee. 
There are no composite plans or plan comparisons justifying the need for proton therapy which would be 
necessary to support need for non-standard indications of proton therapy. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided by an in-network 
provider on October 10, 2022. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that you think that this visit should be 
covered in full. 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. Your 
contract with the Plan says that there is a $800 deductible, and that you must pay a 10% coinsurance of the 
approved amount, and the annual deductible applies for in and out-of-network doctor and other health care 
provider services. 
 
 You have been asked to pay a cost share of $124.42 for the office visit ($124.42 allowed amount x .10 = $12.44 
coinsurance) ($12.44 coinsurance + $111.98 deductible = $124.42). The item or service you asked the Plan to 
waive the cost sharing for falls within the doctor and other health care provider services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which 
applies to doctor and other health care provider services. This cost sharing is a contractual obligation that had 
not been met at the time the office visit was provided on October 10, 2022. Therefore, we decided that the Plan 
does not have to waive the cost sharing for the office visit provided by an in-network provider on October 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on August 
4, 2022, to September 13, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you disagree with the 
copayment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment per visit for physician/practitioner services/specialist.  
 
The enrollee has been asked to pay a $40 copayment per visit for specialist office visits. The total amount you 
are being asked to pay is $120 ($40 x 3 visits = $120). This item/service falls within the physician/practitioner 
services/specialist benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
specialist office visits provided on August 4, 2022, to September 13, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility. 
 
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's functional status is consistent with the post-op condition. The enrollee 
requires pain control and rehabilitation services which may reasonably be provided at several levels of care and 
do not require an IRF admission or frequent physiatry oversight per evidence based and clinical practice 
standards. 
 
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.