Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 15, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
was in hospice on this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health office visits provided from  
May 15, 2021, to August 20, 2021. 
 
You asked the Plan to pay for outpatient mental health office visits. The Plan denied your request. The Plan 
says non-emergent, non-urgent services with out-of-network 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 did not pre-approve the 
services 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 outpatient mental health office visits provided from  
May 15, 2021, to August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyewear provided on February 8, 2022. 
 
You asked the Plan to pay an additional amount for the eyewear. The Plan denied your request. The Plan says 
the provider applied the $150 eyewear benefit from your Plan Mastercard toward your glasses. The balance 
owed is your member responsibility. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
 We looked at the file and the Plan's rules. The file shows that the provider applied the $150 eyewear benefit 
from your Plan Mastercard toward your glasses. Therefore, we decided that the Plan does not have to pay an 
additional amount for eyewear provided on February 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 8, 2021. 
 
You asked the Plan to pay for ambulance services. You say that the claim was filed timely. The Plan denied 
your request. The Plan says Medicare denies a claim for untimely filing if the receipt date applied to the claim 
exceeds 12 months or 1 calendar year from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for ambulance services was not filed until April 29, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for ambulance services provided on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says an IRF admission does not meet the Medicare coverage 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for hypoxemia and congestive heart failure. The medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided 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 IRF admission and services.
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 would benefit from an 
admission to an LTACH to regain a maximum/prior level of functioning and continue multidisciplinary 
approach to care. The Plan denied your request. The Plan says authorization denied because the LTACH 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied.  
 
 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: 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 requested are based on medical 
necessity. The Plan denied your request. The Plan says the enrollee does not require nursing care which would 
be considered skilled services by Medicare. It is documented that the enrollee's clinical condition is stable at 
this time and nursing is not providing skilled 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee with status post right femur dislocation and infection has received enteral 
nutrition and completed a course of intravenous antibiotics. The enrollee had stable and vital signs and had care 
to several wounds. Regarding rehabilitation services, the enrollee was dependent with mobility and care.  
 
The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
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 would like to see your father to go to a SNF 
because he is very weak. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to a skilled nursing facility. 
 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 the enrollee with a small bowel obstruction and COVID-19 infection has received 
oral medications. The enrollee had stable and vital signs and has received physical and occupational 
therapy.  The enrollee was at a supervision to modified independent level for functional mobility including gait 
to 160 feet.  The enrollee required varying assist with assisted daily living skills. 
 
The enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a second opinion to be provided by an OON provider. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services can be provided by an in-network, equally qualified, tertiary (higher) level of care facility. 
 
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 second opinion to be provided by an out-of-network (OON) provider.
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 the enrollee requires inpatient rehabilitation 
admission with active and ongoing therapeutic care of physical and occupational therapy with a minimum of 
three hours of therapy daily. The Plan denied your request. The Plan says there is no documentation that the 
enrollee needs an intensive program with a team of health care professionals and doctors that specialize in 
complex medical needs as well as rehabilitation. Services can be provided at an alternate 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 the enrollee has a past medical history of cervical spine stenosis and dementia 
and is living at home with weakness. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. Medically necessary care can be provided in a 
different 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial and have 
submitted additional information. The Plan denied your request. The Plan says the request for LTACH is 
denied as 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 the enrollee was admitted following a fall and found to have rhabdomyolysis and 
acute on chronic kidney disease requiring hemodialysis. The record indicates that the enrollee is improving but 
still requires acute care services before transitioning to a lower level of care. The medical record does not 
indicate that the enrollee requires services not currently receiving but that would be available at the LTACH 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Ondansetron is not covered under the enrollee's Medicare 
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 Ondansetron.  
 
Benefits for Ondansetron 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on September 
17, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that not be responsible for this cost 
share. The Plan denied your request. The Plan says the cost share 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 $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay a $20 copayment for physical therapy. Physical therapy falls within the Outpatient Rehabilitation Services 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 physical 
therapy provided on September 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on February 26, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that ambulance services are normally covered 
with the $265 copayment. You also say that this claim denied, and you received a bill for $2,057.02. The Plan 
denied your request. The Plan says since no transport was provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 26, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on February 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
March 12, 2022, to March 16, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $325 
copayment per day for days 1 through 5 per benefit period.  
 
You have been asked to pay $1,300 ($325 x 4 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient Hospital Care 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 inpatient hospital stay provided from March 12, 2022, to March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 16, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you were told there would 
be no copayment for the visit. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $50 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay $50 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry office visit provided on February 
18, 2022. 
 
You asked the Plan to waive the copayment for podiatry office visit. You say that all the doctor did was cut 
your toenails so it should be covered. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $25 
copayment for each specialist's office visit.  
 
You have been asked to pay $25 copayment for podiatry office visit. Podiatry office visits fall within the 
Podiatry Services 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 podiatry office visit 
provided on February 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on August 23, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. The Plan denied your request. The Plan says the cost share 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 $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay $20 for physical therapy. Physical therapy falls within the Outpatient Rehabilitation Services 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 physical 
therapy provided on August 23, 2021.