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

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments provided from 
December 13, 2021, to December 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatments. You say that this is a recurring issue 
and every time the provider submits a claim it is denied because the provider is out-of-network.  You say you 
were told by the Plan that the provider was in-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 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. The 
record shows that the provider contracted with other Plan contracts. However, the provider is not contracted 
with your specific plan. Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatments provided from December 13, 2021, to December 28, 2021, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve miscellaneous durable medical equipment, Volara 3-in-
1 respiratory device (E1399). 
 
You asked the Plan to pre-approve Volara 3-in-1 respiratory device. You say that you are requesting 
reconsideration of this denial based on medical necessity. The Plan denied your request. The Plan says 
intrapulmonary percussive ventilators such as the Volara device has not been demonstrated to be reasonable 
and necessary in the home setting. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Volara 3-in-1 respiratory device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve miscellaneous durable medical equipment, Volara 3-in-1 respiratory device (E1399).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 and does not need a PMR physician's close 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. At the current functional level, he does not need IRF therapies consisting of 3 
hours a day, 5 days a week with interdisciplinary management. The enrollee's rehab needs can be safely met in 
an alternate and low intensity 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services received from 
November 9, 2021, to December 28, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you don't agree with 
the charges and you were never at the hospital for minor surgery. The Plan denied your request. The Plan says 
the copayment was applied 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 a $195 
copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, 
observation room, or outpatient surgery services for outpatient hospital services.  
 
 
  You have only been asked to pay a total of $1,228.29 for outpatient hospital services. Please note, you were 
charged the allowed amount or the standard copayment, whichever one was less.  
 
Date of Service Service Allowed Amount Standard 
Copayment 
Member Liability 
November 9, 2021 Treatment Room $84.87 $195 $84.87 
November 9, 2021 Treatment Room $109.80 $195 $109.80 
November 16, 2021 Treatment Room $84.87 $195 $84.87 
November 16, 2021 Treatment Room $109.80 $195 $109.80 
November 23, 2021 Treatment Room $84.87 $195 $84.87 
November 23, 2021 Treatment Room $109.80 $195 $109.80 
November 30, 2021 Treatment Room $84.87 $195 $84.87 
November 30, 2021 Treatment Room $109.80 $195 $109.80 
December 7, 2021 Operating Room $1,056.53 $195 $195 
December 14, 2021 Treatment Room $84.87 $195 $84.87 
December 21, 2021 Treatment Room $84.87 $195 $84.87 
December 28, 2021 Treatment Room $84.87 $195 $84.87 
TOTAL:    $1,228.29 
 
 
Outpatient hospital services fall within the Outpatient Hospital Observation 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 outpatient hospital services received from November 9, 2021, to 
December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics (L3002). 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like to appeal the denial for the 
orthotics. The decision to use with a brace has not been made by the doctor yet. The Plan denied your request. 
The Plan says this item is not a covered benefit as the enrollee's foot condition is Cerebral Palsy therefore, the 
enrollee does not have a qualifying condition for shoe orthotics. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics (L3002).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the outpatient office visit (99214) for rheumatology follow up. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee was seen by the arthritis specialist 
and she needs the results of the x-ray and blood work ordered. The Plan denied your request. The Plan says that 
follow up with the rheumatology office is not medically necessary as the PCP can provide the results and 
follow up with the enrollee. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The health Plan contract specifically says that for medical services, you must have a network primary care 
provider (PCP) who has ordered the care or has told you to use another doctor. The enrollee was referred for 
the office visit by their contracted primary care provider. The requested provider in this case is in network with 
the Plan.  The Plan has not substantiated their reason to continue to deny the PCP recommended in-network 
services. Therefore, we decided that the Plan has to pre-approve the outpatient office visit (99214) for 
rheumatology follow up.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle freedom lite (E0607). 
 
You asked the Plan to pre-approve Freestyle freedom lite. You say that the requested items/services are not 
considered medically reasonable and necessary in this case. The Plan denied your request. The Plan says the 
requested item does not meet the medically necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Suppliers are not required to furnish a specific brand name item 
or mode of delivery to a beneficiary unless prescribed by a physician or treating practitioner to avoid an 
adverse medical outcome. The requested glucose testing system is not a Plan preferred system.  The preferred 
systems are: Roche systems- Accu-Chek Aviva Plus, Accu-Chek Smartview, Accu-Chek Compact Plus, and 
others; OR Trividia systems- TrueMetrix and TrueTrack. Based on this information, we decided that Medicare rules for coverage of Freestyle freedom lite have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Freestyle freedom lite (E0607).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cutting Procedures on the Skin provided on September 3, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Cutting Procedures on the Skin. You say that you would like to appeal the denial 
of the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were 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 Cutting Procedures on the Skin provided on 
September 3, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for SNF long term care, and 
her needs can safely be met at a lower level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that, at the time of admission, the enrollee 
required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no 
skilled nursing needs. As of May 8, 2022, the enrollee did not require any skilled nursing or rehabilitation 
services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable 
period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The 
enrollee did not require skilled therapy to establish a safe and effective maintenance program.  As a practical 
matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of May 
8, 2022. The enrollee did not have any parental medications, complex wound care or nutrition given via a 
feeding tube. The enrollee received skilled care and improved; however, her functional improvement had 
plateaued by May 8, 2022, and she did not require any further inpatient skilled rehabilitation services. The 
enrollees function was at or near her prior level of function and she could be discharged to a lower level of 
care for further services. As of May 8, 2022, the enrollee required custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on October 8, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the members contract indicates the rendered services 
require an authorization/referral to be covered out-of-network. This provider is not a network provider, and the 
services were not referred by 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 Laboratory services provided on October 8, 2021, 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. 
The Plan says that the services needed can safely be received at a different setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis.  She is medically stable and can receive further rehabilitation services at a lower level 
of care.  Although further rehabilitation services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
The enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube.  
She is medically stable without any acute exacerbations of chronic medical problems.  Her physical function is 
at or near her baseline and she can receive services at a lower level of care.  Admission to a SNF for inpatient 
skilled rehabilitation services is not medically 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not able to do things on your own fully. 
You say that if you aren't able to go to the SNF you will be chair-bound. You say that you need SNF care to 
gain your strength back. The Plan denied your request. The Plan says the guidelines for coverage have not been 
met. The Plan says that the enrollee's needs may be met at a lower level of care.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level 
of care. Although further rehabilitation services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
The enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. 
She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is 
at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient 
skilled rehabilitation services is not medically 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic colon cancer 
diagnosed in 2016. Keytruda is not Food and Drug Administration (FDA)-approved for the treatment of 
metastatic colon cancer. Off-label use is not supported by major dug compendia or the medical literature. Use 
is supported for microsatellite instability-high or mismatch repair-deficient cancer but there is no 
documentation of this. The service is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for admission to a long term 
acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for admission to a long term acute care hospital (LTACH).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a transthoracic echocardiogram (TTE) with 
Doppler provided on February 7, 2022. 
 
You asked the Plan to waive the deductible for the TTE with doppler. You say that you were not informed 
which tests would apply to the deductible. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the TTE with doppler was received on 
February 7, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a transthoracic 
echocardiogram (TTE) with Doppler provided on February 7, 2022.