Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that in order for the enrollee to sustain a safe 
and sustainable discharge, LTACH is the best option of care. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an LTACH care. The enrollee can safely receive 
care in another setting, such as skilled nursing facility (SNF) or at home with home health services. 
 
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 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 the 
enrollee is currently receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve a SNF admission. You say that you would like reconsideration based on the 
records submitted.  The Plan denied your request. The Plan says you must receive your care from a 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 
a SNF admission.
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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not 
been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care 
such as at a Skilled Nursing Facility. 
 
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 documents do not support necessity for admission to an IRF and the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitative 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Romosozumab-aqqg injection 
(J3111TB) provided on November 5, 2021. 
 
You asked the Plan to waive the coinsurance for the Romosozumab-aqqg injection. You say that you were told 
multiple times by different people that you would not be held liable for these claims from 2021, because they 
were adjusted in 2022. You also say that before you got the shots you had to get them approved, and you were 
told they were covered, but never informed of a price or benefit. 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered Part B drug.  
 
 
 
 You have been asked to pay a 20% coinsurance for the Romosozumab-aqqg injection. This item/service falls 
within the Medicare Part B prescription drugs 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 coinsurance 
for the Romosozumab-aqqg injection (J3111TB) provided on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist visit provided on 
October 25, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist visit. You say that this provider ended 
up not being able to help you, therefore you feel you should not have to pay a 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). Your contract with the Plan clearly says that you must pay a $20 
copayment for specialty care physician. 
 
You have been asked to pay a $20 copayment for an in-network specialist visit. This item/service falls within 
the specialty care physician 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 in-
network specialist visit provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional 
services. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in their current condition at a skilled nursing facility. You say that the enrollee's needs aggressive physical 
and occupational therapy to ensure they can be safely discharged. The Plan denied your request. The Plan says 
an LTACH admission is not medically necessary, and the enrollee's needs can be met in the current 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. Our 
physician reviewer found that the enrollee is more stable and should only require short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 17, 2022. 
 
You asked the Plan to pay for lab services. You say that you were told to have this done by your primary care 
provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). There was no prior authorization for this service at this lab. Therefore, we decided 
that the Plan does not have to pay for lab services provided on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve the Freestyle Libre continuous glucose monitor. The Plan denied your 
request. The Plan says the enrollee does not require insulin three or more times daily. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre continuous glucose monitor.
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 would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. While the enrollee can 
benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of care 
such as a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close medical 
monitoring with daily physician management as well as prolonged and intensive skilled services. You say that 
the enrollee's medical needs cannot be adequately managed in their current condition at a skilled nursing 
facility. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the 
enrollee can get the services they need in another 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. Our 
physician reviewer found that the enrollee is stable and only requires short-term additional acute care services 
that can safely be provided at the current facility until they are more appropriate for a lower level of care. The 
enrollee does not require services at the LTACH that are not already available at the current 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on August 25, 
2022, to September 28, 2022. 
 
You asked the Plan to waive the copayment for each office visit. You say that you were not informed that there 
was a copayment for each visit. 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). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services, including doctors office visits (specialist office visits). 
 
You have been asked to pay a $40 copayment for each office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist 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. The total you owe is $160 
($40 copayment x 4 visits = $160). Therefore, we decided that the Plan does not have to waive the copayment 
for each office visit provided on August 25, 2022, to September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
August 02, 2022, to August 06, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the copayment for this 
service is too high. 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). Your contract with the Plan clearly says that you must pay a $300 
copayment for inpatient hospital care each time you are admitted to an acute care hospital. 
 
You have been asked to pay a $300 copayment for an inpatient hospital stay. This item/service falls within the 
inpatient hospital care each time you are admitted to an acute care hospital 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 inpatient hospital stay provided on August 02, 2022, to August 
06, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on January 
11, 2021. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copaymet. 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). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery/Medicare-covered surgery or other services provided to you at an ambulatory 
surgical center. 
 
You have been asked to pay a $200 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery or other services provided to you at an ambulatory surgical center 
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 outpatient surgery provided 
on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 05, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on July 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
August 20, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing does 
not meet Medicare coverage criteria. 
 
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 testing services were requested for screening purposes. Excluded from 
coverage are cardiovascular disease screening tests for the early detection of cardiovascular disease or 
abnormalities. There are insufficient medical records to show that the testing was ordered for a specific medical 
problem based on signs and/or symptoms. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary 
cardiovascular screening panel provided on August 20, 2021.