Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $80 more towards this service. We decided that the Plan does not have to 
pay the $180 that is over the credit limit.  
 
You asked the Plan to pay for deluxe frames (V2025), single plano 4.0 lenses (V2100), a routine 
ophthalmological examination (S0621), a determination of refractive state (92015) and an unlisted special 
service, procedure or report (99199) provided on April 25, 2022. You say that you cannot see out of the 
glasses. You also say that they did not dilate your eyes. The Plan says that according to the 2022 EOC, the 
member is responsible for any amount over the $200 retail price for frames and lenses. The Plan also says that 
the member is not responsible for the routine eye exam or any services that are included as part of the exam. 
 
We decided that the Plan has to pay $80 more towards this service ($260 - $180 = $80).  
 
The Plan rules say that they cover one $200 benefit towards the purchase and fitting of the eyeglasses and pair 
of lenses or contact lenses per year. The Plan rules also say that the enrollees routine exam charge will not 
exceed $0 at a Plan optical provider. 
 
The file shows that the allowed amount for the glasses was $380, and the enrollee has a credit of $200. 
Therefore, the enrollee will only be responsible for $180. The file also shows that there is a $0 responsibility 
for the member towards the routine exams and any services that are included as part of the exam. Therefore, the 
Plan is responsible for $80 more towards this service ($260 - $180 = $80).  
 
We also decided that the Plan does not have to pay the $180 that is over the credit limit. 
 
The Plan rules say that they cover one $200 benefit towards the purchase and fitting of the eyeglasses and pair 
of lenses or contact lenses per year. The Plan rules also say that the enrollees routine exam charge will not 
exceed $0 at a Plan optical provider.  
 
The file shows that you are responsible for any cost over the $200 benefit towards the purchase and fitting of 
the eyeglasses and pair of lenses. Therefore, you are responsible for $180. 
 
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: 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that the bed is necessary. The Plan 
denied your request. The Plan says the bed is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the total electric hospital bed have not been met. The rules say a 
total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a 
convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation does not show any change in functional or clinical status other 
than complications of neurogenic bowel. There is no documentation to suggest that you would require daily 
skilled nursing or therapy. Thus, daily skilled services on an inpatient basis in a SNF 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation services so 
you can return home safely. The Plan denied your request. The Plan says the your needs can be met at a lower 
level of care such as 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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from January 11, 2022, to 
May 31, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services 
obtained by the member was rendered by a provider who is not under contract with the health Plan and has 
opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided from January 11, 2022, to May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hemodialysis procedure with single evaluation by a 
physician or other qualified health care professional (CPT code 90935) and unlisted dialysis procedure, 
inpatient or outpatient (90999). 
 
You asked the Plan to pre-approve the services. You say that the enrollee shows problems with kidneys, and 
this is life sustaining treatment that the enrollee needs. The Plan denied your request. The Plan says the 
enrollee's records received do not indicate that they have an emergent or urgent medical condition or are in 
need of specialized service(s) that are not available in the network. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. Medical 
records were not provided to verify if the services are necessary for the enrollee. Therefore, we decided that the 
Plan does not have to pre-approve hemodialysis procedure with single evaluation by a physician or other qualified health care professional (CPT code 90935) and unlisted dialysis procedure, inpatient or outpatient 
(90999).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lantus injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this medication is to be self-administered and is not covered under the enrollee's 
Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lantus injection.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 
26, 2022, to March 27, 2022. 
 You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says no skilled services were 
provided (rehabilitative or nursing), and the SNF level of care coverage during the requested time frame does 
not meet the Medicare coverage guidelines. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from February 26, 2022, to March 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
additional routine transportation trips. The Plan denied your request. The Plan says you exhausted your benefit. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. The 61st trip and beyond is not a covered 
benefit. Your 2022 EOC states up to sixty (60) one-way trips are covered each year (limited to ground transportation only). Therefore, this request exceeds your benefit. Therefore, we decided that the Plan does not 
have to pre-approve thirty (30) additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qulipta. 
 
You asked the Plan to pre-approve Qulipta. You say that the requested drug is medically necessary for 
treatment of the enrollee's migraines. The Plan denied your request. The Plan says the requested drug is 
intended for patient self-administration and is not covered under this Part B Coverage. The Plan says that the 
enrollee does not have Part D coverage through them. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Qulipta.  
 Benefits for Qulipta may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen and 
magnetic resonance elastography. 
 
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. Medicare rules say that MRIs are covered only when they are medically 
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 mild elevation of liver 
enzymes and an ultrasound on July 11, 2022 revealed mild coarsened hepatic texture. There is no 
documentation to support that he is at risk for hepatocellular carcinoma and no lesion was noted in the July 
ultrasound, nor were there any equivocal findings. The MRI of the abdomen and MRI elastography are not 
reasonable or medically necessary at this time. 
 
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 magnetic resonance imaging (MRI) of the abdomen and magnetic resonance elastography.
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 if you go to a rehabilitation center, you will decline 
and you need to gain more strength physically and cognitively. The Plan denied your request. The Plan says 
because the IRF care is not medically necessary, and your needs can be met 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 do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. skilled nursing facility, home health 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the over-the-counter COVID-19 test (K1034) 
purchased May 21, 2021 
 
You asked the Plan to reimburse you for the COVID-19 test. You say that please send refund for COVID home 
test. The Plan denied your request. The Plan says reimbursement for over-the-counter COVID tests are not 
covered under the Plan benefits. Contact your pharmacy to submit these expenses through Original Medicare 
for coverage and payment determination.  
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. This can be submitted directly to Original Medicare for 
reimbursement. Based on this information, we decided that Medicare rules for coverage of the COVID-19 test 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for the over-the-counter 
COVID-19 test (K1034) purchased May 21, 2021
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen 20-gram injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not cover outpatient prescription drugs. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Privigen 20-gram injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA to the SI joint (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the SI joint in the 
setting of sacroiliitis and chronic lumbar back pain have not been demonstrated in the peer-reviewed literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure because of the wide variation in 
efficacy as reported in the literature. Therefore, the request is deemed 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve RFA to the SI joint (CPT code 64625).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 the 
requested SNF care is not medically necessary. Our physician reviewer found the enrollee is medically stable 
and his physical function is near his baseline. He does not require skilled therapy on a daily basis. He has no 
parental medication, complex wound care, or nutrition given via feeding tube and does not require skilled 
nursing on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis at the SNF level of care. 
 
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 skilled nursing facility (SNF) care.