Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supply allowance for therapeutic continuous glucose 
monitor (K00553) receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system 
(K0554). 
 
You asked the Plan to pre-approve the CGM receiver and supply allowance. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says the requested 
clinical records form the provider was not provided to support that the enrollee meets the Medicare criteria. 
 
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 indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM receiver and supply allowance have not 
been met. Therefore, we decided that the Plan does not have to pre-approve supply allowance for therapeutic 
continuous glucose monitor (K00553) receiver (monitor), dedicated, for use with therapeutic glucose 
continuous monitor system (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 1 standard (K0800). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have a chronic health condition and 
are unable to walk more than 20 feet. You need the device to help you with daily life. The Plan denied your 
request. The Plan says the requested wheelchair not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you ambulate using a 4 wheeled walker with a seat and you are able to ambulate 50 feet, 
therefore, exceeding household distances. This means that Medicare rules for coverage of a PMD have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair, group 1 
standard (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient visit services provided on October 20, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient visit services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 Outpatient visit services provided on October 20, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 17, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you were told that the provider was in-network 
provider. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no approved authorization. Also, records show there was no communication prior about the provider being 
an in-network provider for the services rendered. 
 
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 an office visit provided on January 17, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on December 8, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you are a participating provider, and the 
claim should be reprocessed for payment. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was no urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on December 8, 
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home-delivered/post discharge meals. 
 
You asked the Plan to pre-approve home-delivered/post discharge meals. You say that you were unaware that 
you needed an authorization from your doctor for this service. The Plan denied your request. The Plan says the 
authorization request was not received within 14 calendar days of discharge to home after your hospital stay. 
 
The Plan contract covers a Meals (post-discharge) benefit. The Plan contract says there is no limit to the 
number of 28-day meal benefit periods you may receive in a year, as long as request follows a new hospital or 
skilled nursing facility discharge to home and is requested within 14 days of discharge from hospital or skilled 
nursing facility to home.  
 
We looked at the file and the Plans rules. The file shows that the authorization request was not received within 
14 calendar days of discharge to home after your hospital stay. Based on this information, we decided that the 
Plans rules for coverage of home-delivered/post discharge meals have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home-delivered/post discharge meals.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on September 12, 
2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you went to the emergency 
room for a prescription refill and the service did not happen. The Plan denied your request. The Plan says you 
have been charged the correct copayment 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 $90 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the 
Emergency care benefit category. The records show services were provided in the emergency room. 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 emergency room visit on September 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says the member has utilized the benefit of 20 one-way trips for this Plan 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 20 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. The file shows that you have used the 
maximum number of routine transportation trips for this 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 provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the items due to urinary 
incontinence. The Plan denied your request. The Plan says the items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
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. The Plan denied your request. The Plan says your medical and 
rehabilitation needs are not complex. 
 
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 physician reviewer found 
that you were admitted to the acute hospital after a syncopal episode. You were found to be hypoxic and have 
an infection with Covid-19. You were treated medically and remained medically stable.   The most recent therapy notes indicate that you are able to ambulate household distances with a rolling walker 
and stand by assistance. The complexity of your nursing, medical and rehabilitation needs does not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy 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 inpatient rehabilitation facility (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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet 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 you are receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that you require 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on January 4, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the outpatient visit. You say that service was provided to the enrollee out of 
medical necessity, and you would like the claim reprocessed for payment. The Plan denied your request. The 
Plan says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient visit provided on January 4, 2021, by 
an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the continued admission to a SNF is not medically necessary after 5/11. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary. Our physician reviewer found the 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit and extremity study 
provided on December 8, 2021. 
 
You asked the Plan to waive the copayments for the office visit and extremity study. You say that you do not 
agree with the copay assessed. The Plan denied your request. The Plan says you have been charged the correct 
copayment amounts. 
 
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 health plan contract says that enrollees must pay $20 
copayment for a visit to a specialist and $25 copayment for carotid or peripheral vascular ultrasound. 
 
You have been asked to pay a $20 copayment for the office visit and a $25 copayment for the extremity study. 
The total amount you owe is $45 ($20 + 25 = $45). An office visit falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The extremity study falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category.  
 This means that you have been asked to pay the correct amounts 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 copayments for an office visit and extremity study provided on December 
8, 2021.
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 records do not document the need for 
intravenous medications, new tube feeding, ostomy care or daily complex wound care. You were walking 
household distances with a rolling walker with contact guard assistance, and you were supervision to contact 
guard assist for transfers at time of discharge from the acute inpatient rehabilitation facility 04/29/2022. No 
updated therapy notes have been provided since the evaluations in the rehabilitation facility to document 
increased needs. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not document that services in the home with home health care or in a long-term care facility on a 
part time basis are not appropriate in this case. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 14, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you are not sure if you went to the ER 
that day or if you had any services done that day. 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 $50 
copayment for an emergency room visit.  
 
The Plan confirmed verbally that you were seen in the emergency room on January 14, 2022. You have been 
asked to pay a $50 copayment for an ER visit. An ER visit falls within the Emergency 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 an emergency room (ER) visit provided on January 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation stay from October 
8, 2021, through October 19, 2021. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation stay. You say that you were told you 
were going to a skilled nursing facility, but you were billed for inpatient rehabilitative therapy. The Plan denied 
your request. The Plan says copayment 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 $225 
copayment each day, for days 1-6 for Medicare-covered hospital care and a $0 copayment for additional 
Medicare-covered days.  
 You have been asked to pay a total of $1,350 for the inpatient rehabilitation stay ($225/day x 6 days = $1,350). 
The inpatient rehabilitation stay falls within the Inpatient Hospital Care benefit category. The records show 
you were admitted to an inpatient rehabilitation facility. 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 rehabilitation stay from October 8, 2021, through October 19, 2021.