Persius/hicric huggingface dataset:
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 a skilled nursing facility is best for the enrollee. The 
Plan denied your request. The Plan says the enrollee should remain in the inpatient rehabilitation 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 daily 
skilled services are not necessary. Our physician reviewer found the records do not show that the enrollee has 
skilled nursing or therapy needs. He does not meet the severity of illness or intensity of service criteria for a 
skilled nursing facility 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 outpatient home visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient home visits. You say that the enrollee and the provider have 
an established relationship. The Plan denied your request. The Plan says the provider is no longer an in-
network provider, and a list of in-network providers was given to the enrollee that provide the same quality of 
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 
outpatient home visits to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on September 25, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you cannot afford the cost of the service. 
The Plan denied your request. The Plan says you have been 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 diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $197.15, which is less than the $325 copayment for the MRI. The MRI 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 copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on September 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital care after March 7, 2022. 
 
You asked the Plan to pre-approve continued inpatient hospital care. You say that the enrollee still needs 
inpatient care. The Plan denied your request. The Plan says the enrollee does not require inpatient hospital care 
March 7, 2022, onward. 
 
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 continued inpatient hospital care. Our 
reviewer says that inpatient hospital care after March 7, 2022, is not medically necessary. Our physician 
reviewer found as of this date, the enrollee could have been safely transitioned to a lower 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 continued inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued inpatient hospital care after March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 11, 2021. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing is 
not a benefit for the diagnoses listed on the claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The file shows that Hemoglobin A1c and Vitamin D testing was provided. 
In this case, there are insufficient records to show that the enrollee presented with a deficiency or other 
symptoms that prompted testing. Medicare does not cover this testing for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate screening test rendered on September 16, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you exhausted the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that PSA screening is covered once every 12 months. 
 
We looked at the file and Medicare rules. The file shows that you received a PSA screening on July 7, 2021 
that the Plan covered. The screening on September 16, 2021 was performed less than 12 months from your 
previously covered exam. Therefore, we decided that the Plan does not have to pay for the prostate screening 
test rendered on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on May 21, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this testing was billed correctly. The Plan denied your request. The Plan says this claim was not billed with the 
correct POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing (81479) provided on May 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for a psychiatric diagnostic evaluation (90791) rendered on June 17, 2021. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that this appointment on June 17, 
2021, was coded incorrectly saying it was an evaluation, when that had already been done. You also say you do 
not feel that you owe this, since you have this Plan. The Plan denied your request. The Plan says that the Plan 
covers one screening for depression per year, which was utilized on June 3, 3032, and there is no coinsurance, 
copayment, or deductible for an annual depression screening visit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for psychiatric diagnostic evaluation by a contract provider. The file does not show that the 
Plan provided notice that psychiatric diagnostic evaluation would not be covered. Under Medicare rules, this 
means psychiatric diagnostic evaluation is considered approved by the Plan. Therefore, we decided that the 
Plan has to pay for psychiatric diagnostic evaluation (90791) rendered on June 17, 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: 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 these services are medically necessary. 
The Plan denied your request. The Plan says that your records do not show that you require continued 
treatments and care that can only be given in a hospital setting. 
 
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. You appear 
to be improving but require short-term additional acute care services at this time that can be safely administered 
at the current facility until appropriate for a lower level of care. You do not require services at the LTACH that 
are not already available at the current facility. There are no services at the LTACH that you require that are 
not already available and covered at the current facility. Our physician reviewer found that your condition does 
not meet Medicare criteria for LTACH 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 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 long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care she needs in the hospital 
where she is now and there is no need to transfer to the LTACH at this time. 
 
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. The patient 
appears to be improving and should only require short-term additional acute care services at this time that can 
be safely administered at the current facility until appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you do not know why the Plan did 
not pay for the service. The Plan denied your request. The Plan says you have been 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 $110 
copayment for radiological diagnostic services, not including X-rays.  
 
You have been asked to pay $107.60, which is less than the $110 copayment for the ultrasound. Please note 
that the Plan will only make payment on costs that exceed the copayment amount.  The ultrasound 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 copayment for an ultrasound of the abdomen provided on 
November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  Magnetic resonance imaging (MRI) on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for Magnetic resonance imaging (MRI). You say that you do not 
have money for this. The Plan denied your request. The Plan says the copayment you are being charged 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 a $250 
copayment for Magnetic resonance imaging (MRI).  
 
 
 You have been asked to pay a $250 copayment for Magnetic resonance imaging (MRI). Magnetic resonance 
imaging (MRI) 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 copayment for  Magnetic resonance imaging (MRI) on 
November 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Xtandi tablet (J8999). 
 
You asked the Plan to pre-approve the Xtandi tablet. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says this is a self-administered drug. 
 
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 the Xtandi tablet (J8999).
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF need. 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. 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. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of arm and leg arteries 
provided on November 11, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not be 
responsible for the copayment since the test was done on a false diagnosis. The Plan denied your request. The 
Plan says you have been 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 $125 
copayment for radiological diagnostic services, not including X-rays.  
 
You have been asked to pay $83.22, which is less than the $125 copayment for the ultrasound. The ultrasound 
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 copayment for an ultrasound of arm and leg arteries provided on November 
11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) telehealth 
visit provided on October 28, 2021. 
 
You asked the Plan to waive the copayment for the PCP telehealth visit. You say that this was only a telehealth 
visit and you have never had a copayment before. The Plan denied your request. The Plan says you have been 
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 $10 
copayment for each visit with your PCP, including telehealth visits.  
 
You have been asked to pay a $10 copayment for the PCP telehealth visit. The PCP telehealth visit falls within 
the Physician/Practitioner Services, Including Doctor's 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 a primary care physician (PCP) telehealth visit provided on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the device wakes you up if you have low 
blood sugar. The Plan denied your request. The Plan says you take set doses of insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
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 self-administered drugs are not covered. 
 
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 Dupixent.  
 
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair. 
 
You asked the Plan to pre-approve the manual wheelchair. You say that you feel that you require both 
wheelchairs and that Medicare has always paid for both. The Plan denied your request. The Plan says this is a 
duplicative request as a power wheelchair serves the same purpose as the requested manual chair. 
 
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 power wheelchair. A power wheelchair serves the same purpose as the manual 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a lightweight manual wheelchair.