Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy evaluation provided on October 15, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the occupational therapy evaluation. You say that the enrollee has a referral, and 
you would like the claim reprocessed. The Plan denied your request. The Plan says no prior authorization was 
obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 occupational therapy evaluation provided on 
October 15, 2021, by an out-of-network (OON) provider.
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 records do not show that you are stable to leave the hospital. 
 
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 are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. 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. 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 22, 2021, 
through August 29, 2021. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 17, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for home health services 
provided from August 22, 2021, through August 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on May 28, 2021, June 4, 
2021, and June 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic treatment. You say that prior claims have been paid for services 
provided to the enrollee. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and the enrollee's primary care physician did not refer the enrollee. Also, the services 
rendered was not urgent or emergent in nature. 
 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 chiropractic treatment provided on May 28, 2021, 
June 4, 2021, and June 11, 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 nursing facility care provided on April 28, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that services were provided to the enrollee out 
of medical necessity. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers. 
  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 nursing facility care provided on April 28, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from January 6, 2021, through 
January 26, 2021 with diagnosis code S36.039A, unspecified laceration of spleen, initial encounter. 
 
You asked the Plan to pay for inpatient services provided from January 6, 2021, through January 26, 2021 with 
diagnosis code S36.039A, unspecified laceration of spleen, initial encounter. The Plan denied your request. The 
Plan says during the audit of this claim, an itemized bill was requested and not provided and therefore, the 
claim was partially denied. Upon appeal, the itemized bill was not provided after multiple attempts to obtain. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim as billed. Therefore, we decided that the Plan does not have to pay for inpatient 
services provided from January 6, 2021, through January 26, 2021 with diagnosis code S36.039A, unspecified 
laceration of spleen, initial encounter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on April 21, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that service was provided to the enrollee out of 
medical necessity. The Plan denied your request. The Plan says the rendering and referring providers are both 
out-of-network providers. 
  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 nursing facility care provided on April 21, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Glutathione intravenous therapy (J3490 x 4) provided on 
August 23, 2021, by a non-certified Medicare provider. 
 
You asked the Plan to pay for the Glutathione intravenous therapy. You say that the provider in this case is 
listed as in network on the website. You also say that this has been paid in full in the past. The Plan denied your 
request. The Plan says the provider in this case is not a certified Medicare provider. The Plan also says that 
payment cannot be made to a provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Glutathione intravenous therapy 
(J3490 x 4) provided on August 23, 2021, by a non-certified Medicare provider.  
 
Benefits for the Glutathione intravenous therapy 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 30, 2021, to September 18, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service 
needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not 
meet severity of illness or intensity of service criteria for 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 30, 2021, to 
September 18, 2021.
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 appropriate care in the acute care 
hospital. 
 
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 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 he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate coating (V2784) and progressive lens options (V2750) purchased on October 26, 2021.
You asked the Plan to pay for the lens enhancements. You say that these eyeglasses were necessary after your cataract surgery, and you do not understand why you have only been reimbursed $48 when you paid $313. The Plan denied your request. The Plan says this claim was processed correctly, and your reimbursement was assessed in accordance with your contract. According to the statement and receipt provided, you paid $0 for the lenses at the time of service, $48 for the frames, and $265 for the lens enhancements. Lens enhancements are not covered by Medicare or the Plan, and you are responsible for these services.
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to aid vision or magnify images. This rule applies no matter the size, form or technological features of the device. This rule does not apply to post-surgical prosthetic lenses after surgery in which the lens of the eye was removed. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. Covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered. We looked at the file and the Plan's rules. Based on the documentation provided, you have received the full reimbursement amount for covered services. Documentation shows that you paid $0 for the lenses and $48 for the standard frames provided on October 26, 2021. The remaining amount you paid went toward the cost of the lens enhancements, which are not covered services and are your responsibility. Therefore, we decided that the Plan does not have to pay for the polycarbonate coating (V2784) and progressive lens options (V2750) purchased on October 26, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Ziextenzo. 
 
You asked the Plan to pre-approve Ziextenzo. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan 
requires a trial of at least 2 of Neulasta, Fulphila, or Udenyca before it will approve Ziextenzo. 
 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 Ziextenzo. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Ziextenzo. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs or Neulasta, Fulphila, or Udenyca. The 
record does not show that these drugs would likely be less effective and/or have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Ziextenzo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist office visits provided on October 12, 2021, to 
October 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visits. You say that you were referred to this provider after 
your inpatient stay. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows you were referred by an out-of-network provider for care from an out-of-network provider. 
Therefore, we decided that the Plan does not have to pay for specialist office visits provided on October 12, 
2021, to October 26, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an allograft. 
 
You asked the Plan to pre-approve allograft. You say that the enrollee is in pain and in need of further 
treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this 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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large scale, long-term peer-reviewed literature that shows allograft to 
be an effective and/or safe treatment for the enrollee's condition. There is no compelling rationale or 
extenuating circumstance presented to support the necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an allograft.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit provided on November 8, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visit. You say that your primary insurance was cancelled, and 
you are entitled to a reimbursement for this claim. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 psychotherapy visit provided on November 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 25, 2021. You asked the Plan to pay for the testing services. You say that services were provided in good faith. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim provided lists a place of service as an independent laboratory. We looked at the file and the rules. If 
an independent lab bills for services, the place where the sample was taken is reported as the place of service. 
The records do not indicate that the specimen was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of an implant (20670). 
 
You asked the Plan to pre-approve the removal of an implant. You say that this is a dental procedure but 
necessary to remove the implant, and you would like to know if it is covered by the Plan. The Plan denied your 
request. The Plan says you do not meet any of the applicable circumstances for this service to be covered. The 
Plan also says that you do not have a plan with supplemental dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. Medicare rules also 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 removal of an implant. Our 
reviewer says that the removal of an implant does not meet the criteria for coverage. Our physician reviewer 
found the requested removal of the implant bodies is to be considered a dental service. It is primarily a service 
that is connected with the care, treatment, filling, removal or replacement of teeth or structures directly 
supporting teeth. Our reviewer found that the implants were placed to replace the missing teeth in that region, 
but had failed thereby requiring removal. Our physician reviewer also found that the removal of the implants 
would then lead to other methods of tooth replacement. 
 
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 removal of an implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a removal of an implant (20670).