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

 
We decided that the Plan does not have to pay for a physician or allowed practitioner re-certification for 
Medicare-covered home health services under a home health plan of care (patient not present) provided on 
November 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a physician or allowed practitioner re-certification for Medicare-covered home 
health services under a home health plan of care (patient not present). You say that it is the nursing facilities 
responsibility to get authorizations for their patients. The Plan denied your request. The Plan says the provider 
is out-of-network with the Plan, and authorization was not obtained prior to the services being 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 a physician or allowed practitioner re-certification 
for Medicare-covered home health services under a home health plan of care (patient not present) provided on 
November 17, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard frames (V2020), lens, polycarbonate or equal, 
any index, per lens (V2784), progressive lens, per lens (V2781), and tint, photochromatic, per lens (V2744) 
provided October 13, 2021. 
 
You asked the Plan to pay for the routine eyewear. You say that the Medicare & You booklet does not say 
anything about waiting two years. The Plan denied your request. The Plan says the enrollee has exceeded the 
frequency limit for routine eyewear. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every two years. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that routine eyewear was 
previously covered on February 10, 2020. Based on this information, we decided that the Plan's frequency limit 
for coverage of the routine eyewear has been exceeded. Therefore, we decided that the Plan does not have to 
pay for the standard frames (V2020), lens, polycarbonate or equal, any index, per lens (V2784), progressive 
lens, per lens (V2781), and tint, photochromatic, per lens (V2744) provided October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on October 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and the referring 
provider involved in these services is a non-participating provider with the Plan. The Plan also says that they 
did not authorize any services for the rendering or the referring 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 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 drug testing provided on October 1, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on October 18, 
2021. 
 
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the deductible applied correctly 
based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to Physician/Practitioner Services 
Including Doctor's Office Visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $300 deductible which applies to Physician/Practitioner 
Services Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at 
the time the office visit was received on October 18, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for an office visit provided on October 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 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 pay for the admission. Our reviewer says that the 
requested admission is not medically reasonable or necessary. Our physician reviewer found that you have 
remained medically stable, and was admitted from home for physical therapy. You did not require any skilled 
services on a daily basis in inpatient care. You were not expected to make measurable gains within a reasonable 
and predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care 
tasks. You did not require skilled therapy to establish a safe and effective maintenance program. As a practical 
matter, you did not require any skilled services on an inpatient basis, at a SNF level of care. Your physical 
function was at or near her baseline and you could have received further services at a lower level of care. 
Admission to the nursing facility at a skilled level of care for inpatient skilled services was not medically 
necessary. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI and CT scan provided on May 26, 
2021. 
 
You asked the Plan to waive the copayment for the MRI and CT scan. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $150 copayment for the MRI and a $150 copayment for the CT scan. MRIs and 
CT scans fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
Based on your contract with the Plan, the cost-sharing for these tests is only grouped when the same typeof test 
is performed n the same day. 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 MRI and CT scan 
provided on May 26, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drug(s). There is no documentation provided indicating that the Plans required drug(s) would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
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. The enrollee is walking 
household distances with a rolling walker with close supervision and is close supervision for transfers. 
Provided records do not document a significant decline in the enrollees functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuroablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
procedure is considered experimental or investigational. 
 
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 the requested services. Our physician 
reviewer found that the enrollee has bilateral shoulder pain. Diagnostic suprascapular nerve blocks produced 
50% pain relief. The request is for RFA of the suprascapular nerve. This would be considered an experimental/ 
investigational procedure.  Therefore, it is deemed not medically reasonable or necessary. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve neuroablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
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 with respiratory distress in the setting of chronic 
obstructive pulmonary disease and congestive heart failure exacerbations. The record indicates that the enrollee is clinically unstable with cardiac dysrhthymia and pleural effusions and requires ongoing acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the 2 at-home coronavirus tests provided on January 15, 2022. 
 
You asked the Plan to pay for the at-home tests. You say that you went to the pharmacy to get at-home 
coronavirus tests before you had visitors over. You say that you thought the test would be covered based on the 
president stating all Americans with insurance can go to any pharmacy and get one for free. The Plan denied 
your request. The Plan says that the Biden administrations announcement of coverage for at-home tests applies 
only to commercial health plans. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file indicates that the Plan is using undated/out of date rule to 
deny this claim. The record shows that the current guidance indicates that plans will pay for at home tests 
purchased starting January 15, 2022. Therefore, we decided that the Plan has to pay for the 2 at-home 
coronavirus tests provided on January 15, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility 
(IRF). The enrollee no longer requires daily skilled nursing and/or skilled therapy services. She could benefit 
from continued intermittent services at a lower level of care. Although the enrollee made slow progress with 
therapy, her functional improvement has plateaued, there is no indication that transfer to a skilled nursing 
facility is required. She can continue to receive skilled rehab services at the current IRF or be stepped down to 
a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab 
facility. Admission to a SNF for inpatient skilled rehab services is not medically necessary. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on 
October 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service was inappropriate for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report documents "Sedation Times Physician; Start: 17:01:03; End: 17:46:54.  In this case, time is supported for this CPT 
code. However, the procedure report does not include documentation of the presence of an independent trained 
observer to assist in monitoring patient. The procedure code was not reported with a modifier, to indicate 
physician work related to moderate sedation.  
 
We looked at this coder'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 pay for moderate sedation services provided to the enrollee on October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles for a wheelchair. 
 
You asked the Plan to pre-approve the handles. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve push handles for a wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the patient requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. Records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. There is no 
documentation that daily skilled services are required. The patient is walking close to household distances with 
a rolling walker with contact guard assistance and is contact guard assist for transfers when he is willing to 
participate with therapy. The provided records do not document a significant decline in the patients functional 
status and a willingness to work with therapy to necessitate daily inpatient skilled therapy services. There is no 
documentation that the patient requires the services on an inpatient basis, only in a skilled nursing facility 
setting. The 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).