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

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 30, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $25 copayment for Physician/Practitioner services/specialist office.  
 
The enrollee has been asked to pay a $25 copayment for specialist office visit. This item/service falls within the 
Physician/Practitioner services/specialist office 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 visit provided on July 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on March 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a drug test. You say that you are appealing with supporting records The Plan 
denied your request. The Plan says services rendered by non-participating providers require prior authorization. 
 
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 drug test provided on March 29, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for a bone density DEXA/test scan provided on 
July 20, 2022. 
 
You asked the Plan to provide coverage for a bone density DEXA/test scan. You say that you have 
osteoporosis and your doctor recommended the scan again this year. The Plan denied your request. The Plan 
says another bone density DEXA/test scan is not medically necessary 
 
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 provide coverage for the bone density DEXA/test 
scan. Our reviewer says that the bone density DEXA/test scan is not medically necessary. Our physician 
reviewer found in this case, the record indicates that you have osteoporosis and underwent a DEXA scan in 
March 2021. The provided record indicates that the requested test was ordered at your request. The record 
provided does not document the medical necessity of performing a repeat DEXA  scan at this time. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria 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 bone density DEXA/test scan have not been met. Therefore, we decided that 
the Plan does not have to provide coverage for a bone density DEXA/test scan provided on July 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you are unable to drive to 
appointments due to glaucoma and cataract on both eyes, dementia, and heart issues, among other illnesses. 
The Plan denied your request. The Plan says you are only eligible for 20 one-way transportation trips per year. 
The Plan also says that once you have exhausted those 20 one-way trips, you are not eligible for additional 
transportation trips until the beginning of the next year. 
 
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 a maximum of up to 20 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. The record shows that you have exhausted 
your allowed benefit of 20 rides for the 2022 calendar year. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve additional transportation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on August 1, 
2022, and a psychotherapy visit provided on August 17, 2022 by an OON provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation and a psychotherapy visit. You say that you 
do not agree with the denial of payment and you are asking the Plan to reconsider payment. The Plan denied 
your request. The Plan says this is not covered by this type of doctor or specialist and no referral or prior 
authorization was provided to the Plan. 
 
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 psychiatric diagnostic evaluation provided on 
August 1, 2022, and a psychotherapy visit provided on August 17, 2022 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you had a total knee 
replacement in 2019. You say that you are still in excruciating pain. You also say that you believe that if you 
get a nutritionist then you will start better eating habits which would ease your knee pain. The Plan denied your 
request. The Plan says the requested service is not covered for the purpose it is being requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 14, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the 
out-of-network services were not authorized. 
 
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 physical therapy services provided on July 14, 
2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement group 3 power wheelchair and 
accessories (K0861, K0108, E2361, E1028x2, E2377, E2313, E1007, E0955, E1012, E2311, E2607). 
 
You asked the Plan to pre-approve a replacement group 3 power wheelchair and accessories. You say that you 
disagree with the denial. The Plan denied your request. The Plan says the current wheelchair can be repaired 
and has not reached reasonable useful life, as it is less than 5 years old, and it has received repairs as recently as 
March 2022 from original vendor. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a group 3 power wheelchair. A group 3 power wheelchair serves the same 
purpose as the replacement group 3 power wheelchair and accessories you are requesting. Therefore, we 
decided that the Plan does not have to pre-approve a replacement group 3 power wheelchair and accessories 
(K0861, K0108, E2361, E1028x2, E2377, E2313, E1007, E0955, E1012, E2311, E2607).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure machine (A4670). 
 
You asked the Plan to pre-approve an automatic blood pressure machine. You say that the item is medically 
necessary. The Plan denied your request. The Plan says you are not receiving dialysis. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure machine 
(A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 21, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the treatment received by the 
member was medically necessary. The Plan denied your request. The Plan says care received from an out-of-
network provider will not be covered unless prior authorization is obtained. 
 
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 subsequent nursing facility care provided on June 
21, 2022, by an out-of-network (OON) provider.
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 needs LTACH care. The 
Plan denied your request. The Plan says LTACH care is not medically necessary. 
 
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 there is no documentation provided indicating medical necessity for admission to 
a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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: 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 is not medically 
necessary. 
 
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 does not require intensive rehabilitation services to regain function after 
an uncomplicated hip fracture repair. The enrollee does not require frequent physiatry oversight. 
 
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 pre-approve an interim partial denture (D5820). 
 
You asked the Plan to pre-approve the dental item. You say that your lower dental work was approved. You 
say that the upper dental work was denied. You also say that you would like to appeal this. The Plan denied 
your request. The Plan says interim partial denture is not listed as a covered dental item. 
 
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 interim partial denture is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
an interim partial denture (D5820).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on June 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained before the service 
was rendered. The Plan also says that the service 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the office visit (99214) provided on June 10, 2022, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an angiography and stenting procedures. 
 
You asked the Plan to pre-approve an angiography and stenting procedures. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the request is not 
medically necessary. 
 
The Plan follows Medicare rules. The rules say that PTA and stenting of vessels is covered only when all of the 
conditions listed in the Medicare rules section of this letter have been met. 
 
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 an angiography and stenting 
procedures. Our reviewer says that the requested services are medically reasonable and necessary in this case. 
Our physician reviewer found that the available documentation meets coverage criteria and supports the 
medical necessity of the treatments in question. You have documented throbbing pain in the toes of the left 
foot, worse at rest, that has been determined to be ischemic rest pain. As this is considered a limb-threatening 
degree of ischemia, angiography and possible intervention are both reasonable and medically necessary. In this 
case, your examination and clinical interpretation trumps the Quanta flow results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an angiography and stenting procedures have been met. Therefore, we decided 
that the Plan has to pre-approve an angiography and stenting procedures.  
 
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 outpatient intravenous therapy to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient intravenous therapy. You say that you will not go to the 
recommended in-network provider because of the way they treat you. The Plan denied your request. The Plan 
says this provider is out-of-network with the Plan and you can be treated by an in-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 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 
outpatient intravenous therapy 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 pay for a glycosylated hemoglobin test provided on July 25, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a glycosylated hemoglobin test. You say that this service was marked as no 
authorization required for any outpatient places of service in Plan prior authorization lookup. You also say this 
physician provided medically necessary services in good faith. The Plan denied your request. The Plan says the 
rendering provider, the referring provider, and the facility are non-participating with the Plan. The Plan also 
says that services rendered by a non-participating provider requires prior authorization.  
  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 glycosylated hemoglobin test provided on July 
25, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that it is medically necessary for the enrollee to receive 
SNF care. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity for 
admission to a SNF and the enrollee can receive the care that they need at a home setting with home care 
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 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 that there are no identifiable skilled nursing service needs. There are identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis. This enrollee does not meet severity of illness or intensity of service criteria for 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 pre-approve SNF care.