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

 
We decided that the Plan does not have to pay for an eye refraction provided on October 22, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the benefit is 
limited to once per year as part of a comprehensive eye exam per the vision benefits. The Plan has already paid 
for services on September 21, 2021 under claim 820212930650253 from the same provider. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services 1 per calendar year. 
 
We looked at the file and the Plan's rules. The file shows that you have exceeded the limit for an eye refraction. 
Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary The Plan denied your request. The Plan says the enrollee does not meet the Medicare LCD coverage 
criteria. 
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that the records do not 
show that the enrollee had a minimum of 80% relief of pain from the 2nd MBB.  The review has determined 
that the requested RFA is not medically reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tendon sheath incision for trigger finger 
(26055) provided on December 10, 2021. 
 
You asked the Plan to waive the copayment for a tendon sheath incision for trigger finger. You say that you 
would like the claims to be reviewed because you believe the surgery should be covered without a copayment, 
and you have been charged for the ambulatory surgical facility on both a facility claim, and a provider claim. 
The Plan denied your request. The Plan says you were 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 $325 
copayment for Medicare-covered surgical services.   
You have been asked to pay a $325 copayment for a tendon sheath incision for trigger finger. A tendon sheath 
incision for trigger finger falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 tendon sheath incision for trigger finger (26055) provided on December 10, 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 states that IRF is the enrollee's best shot at returning 
home independently. The enrollee requires speech language pathology for cognitive remediation along with 
physical and occupational therapies. The Plan denied your request. The Plan says denied authorization because 
IRF is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled 
nursing facility (SNF). 
 
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 close physician supervision 3 times 
per week for the ongoing management of any active or acute exacerbation of chronic medical conditions. There 
are no rehabilitation nursing needs identified or documented in the record. At the current functional level, the 
enrollee is more appropriate for skilled nursing facility rehabilitation, and the enrollee does 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. 
 
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 the continuation of the skilled nursing facility (SNF) 
service. 
 
 
 You asked the Plan to pre-approve the continuation of the SNF service. You say that you were 'set up' because 
the provider saw you walking with a walker and is now being discharged. You state that you cannot put 
pressure on your foot. The Plan denied your request. The Plan says authorization denied because the 
continuation of SNF admission is not medically necessary, and you were issued a valid Notice of Medicare 
Non-Coverage (NOMNC). 
 
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 continuation of the SNF service. 
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not 
require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional 
nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last 
covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or 
other skilled nursing SNF need beyond the last covered date. Your functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. You 
do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" 
in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a skilled 
nursing facility setting beyond the last covered date. 
 
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 continuation of the SNF service have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the continuation of the skilled nursing facility (SNF) service.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation for open heart surgery to be provided by 
an OON provider. 
 
You asked the Plan to pre-approve the consultation for open heart surgery. You say that you need heart 
surgery. The Plan denied your request. The Plan says they have referred you to an in-network provider who can 
provide this service. 
 
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 
a consultation for open heart surgery to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is not at her baseline and is very 
dependent and would benefit from therapy each day to regain strength. The Plan denied your request. The Plan 
says authorization denied because IRF is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility (SNF). 
 
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 close supervision by a physician 3 
times per week for the ongoing management of any active or acute exacerbation of chronic medical conditions. 
There are no rehabilitation nursing needs identified or documented in the record. The enrollee is more 
appropriate for an SNF admission, and does 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on December 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that your primary care physician's office 
directed you to the facility to get care. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider, and it was confirmed with the enrollee's primary care physician that no referral was 
made to see the out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on December 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 2, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider send the testing to 
your laboratory because it is medically required for the enrollee's treatment. The Plan denied your request. The 
Plan says both the rendering and referring providers are both out-of-network providers 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 the laboratory services provided on December 2, 
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 rheumatology services to be provided by an out-of-
network (OON) provider. 
 You asked the Plan to pre-approve rheumatology services. You say that you need to see a rheumatologist. The 
Plan denied your request. The Plan says you must use network providers to get medical care and services when 
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 OON 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 
rheumatology services 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 waive the coinsurances for an injection, the medical supply, and the 
diagnostic test provided on November 9, 2021. 
 
You asked the Plan to waive the coinsurances for an injection, the medical supply, and the diagnostic test. You 
say that you were never told of these extra charged and would like them removed. The Plan denied your 
request. The Plan says the claim processed correctly, and the cost share was assessed 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 20% 
coinsurance for each Medicare-covered Part B drug, a 20% coinsurance for Medicare-covered medical supply, 
and a 10% coinsurance for Medicare-covered non-radiological diagnostic services.  
 
The total amount allowed for the injection was $238.20 with a coinsurance of $47.64 ($238.20 total amount 
allowed x 20% coinsurance). The total amount allowed for the medical supply was $380 with a coinsurance of 
$76 ($380 total amount allowed x 20% coinsurance). The total amount allowed for the diagnostic test was 
$62.73 with a coinsurance of $6.27 ($62.73 total amount allowed x 10% coinsurance). The total amount of the 
coinsurance combined for the date of service was $129.91 ($47.64 coinsurance + $76 coinsurance + $6.27 
coinsurance). 
 
You have been asked to pay a $129.91 coinsurance for an injection, the medical supply, and the diagnostic test. 
The injection falls within the Medicare Part B Prescription Drugs benefit category. The medical supply and the 
diagnostic test 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 coinsurances for an injection, the medical supply, and the 
diagnostic test provided on November 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission to be 
provided by a network facility. 
 
You asked the Plan to pre-approve the SNF admission. You say that the SNF is medically necessary. The Plan 
denied your request. The Plan says authorization denied because the SNF admission is not medically necessary 
and your needs can be met at a lower level of care, such as outpatient therapy in residential long-term care or home with home health services. 
 
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 daily skilled services are not necessary. Our physician reviewer found that based on the documentation 
provided, you do not qualify for SNF coverage starting April 5, 2022. You do not have documented skilled 
nursing needs, though ongoing, intermittent monitoring of your electrolytes was necessary. You do have 
documented skilled therapy needs to improve strength and endurance. Daily skilled services were reasonably 
required to establish a maintenance program and/or to prevent deterioration of your condition. 
 
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 to be provided by a network facility.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy (97110, 97530, 97535) provided from September 1, 
2021, to September 30, 2021. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the provider failed to obtain prior authorization for these services 
as required, and all services that are obtained from non-Plan approved facilities or providers must follow 
appropriate policies for compensation of services rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to send the correct evidence of Coverage (EOC). The Plan sent 
the 2020 Evidence of Coverage, when the Plan should have sent the 2021 Evidence of Coverage. Therefore, we 
decided that the Plan has to pay for physical therapy (97110, 97530, 97535) provided from September 1, 2021, 
to September 30, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye exam to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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. 
 
You are not a network provider with the Plan. The Plan has network providers available who can provide the 
service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. 
Therefore, we decided that the Plan does not have to pre-approve an eye exam to be rendered 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 outpatient visit for the evaluation and management of 
a new patient to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that the specialist that you requested has 
previously treated you and that if you can go to this specialist, you will feel okay again after the 
treatment. The Plan denied your request. The Plan says the treatment is not an emergency and can be safely 
rendered 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 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 outpatient visit for the evaluation and management of a new patient to be provided by an out-of-network 
(OON) provider.