Persius/hicric huggingface dataset:
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. You say that the enrollee requires intensive medical care and 
intensive therapy that cannot be provided in a lower level of care. The Plan denied your request. The Plan says 
criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing 
needs can be provided 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 is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or 
documented. At the current functional level, the enrollee does not need 3 hours a day for 5 days a week of 
therapies with multidisciplinary approach in an IRF. The documentation does not support medical necessity 
due to lack of medical complexity, current functional level, and nursing needs for admission to an IRF. While 
the enrollee would benefit from physical therapy and occupational therapy, the enrollee's needs can be safely 
provided in an alternate and lower intensity 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the mental health services. You say that you would like to continue 
receiving care from this provider. The Plan denied your request. The Plan says multiple in-network providers 
are available for necessary care. 
 
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 
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the podiatry visits. You say that you would like to continue seeing this 
provider. The Plan denied your request. The Plan says there are in-network providers available that can provide 
necessary care. 
 
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 
podiatry visits to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pelvic floor therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve pelvic floor therapy. You say that you need this service to continue healing 
and should be covered. The Plan denied your request. The Plan says there was no preauthorization (this is 
different than a referral) for an Out-Of-Network provider or facility, and this was not an emergency. Therefore, 
the decision is upheld. 
 
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 
pelvic floor therapy to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve aquatic therapy services. The Plan denied your request. The Plan says the 
enrollee must receive care from a provider within the network that is contracted for those services. The Plan 
also says that this is not an emergency, and the service is available in-network. 
 
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 
aquatic therapy services to be provided 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 practitioner service provided on June 15, 
2022. 
 
You asked the Plan to waive the deductible for doctor's office visit. You say that you were not aware that your 
PCP was no longer in-network 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 $191.13 
deductible for Medicare-covered primary care physician (PCP) services.  
 
You have been asked to pay $191.13 deductible for doctor's office visit. This item/service falls within the 
Medicare-covered primary care physician (PCP) services 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 deductible for practitioner service provided on June 15, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on November 19, 2021. 
 
You asked the Plan to pay for the ambulance transport. The Plan denied your request. The Plan says they are 
not responsible for payment because the member was enrolled in hospice at the time services were provided. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transport provided on November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA disc. 
 
You asked the Plan to pre-approve VIA disc. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 VIA disc. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested percutaneous injection of allogenic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection (VIA disc), in this case, 
is 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 VIA disc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve VIA disc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3010). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare-covered vision care provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for vision care. You say that you do not agree with copayment 
assessed. 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 $35 
copayment for visit to an ophthalmologist or optometrist for Medicare-covered vision care.  
 
You have been asked to pay $35 copayment for vision care. This item/service falls within the visit to an 
ophthalmologist or optometrist for Medicare-covered vision 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 Medicare-covered vision care provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are appealing the decision because you would 
like a second opinion. The Plan denied your request. The Plan says the enrollee can get their care from an out-
of-network provider; however, in most cases that provider must be eligible to participate in Medicare. Except 
for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If the enrollee 
receives care from a provider who is not eligible to participate in Medicare, the enrollee will be responsible for 
the full cost of the services they receive. Check with the provider before receiving services to confirm that they 
are eligible to participate in Medicare. 
 
 
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 
office visit to be provided by an out-of-network (OON) provider.
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 you need SNF care for further therapy to be able to 
resume quality of life. The Plan denied your request. The Plan says your request does not meet Medicare 
guidelines because you are receiving adequate and necessary intensive rehabilitation in the inpatient 
rehabilitation facility. Transfer to a SNF for inpatient skilled rehabilitation services 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (power operated vehicle). 
 
You asked the Plan to pre-approve power scooter. You say that you need this to go outside and go to the store. 
The Plan denied your request. The Plan says you do not meet criteria for a power mobility device. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
Your home has not been evaluated for use of a power mobility device within the home. You are requesting this 
power scooter for activities outside of the home. Although this item may be helpful, neither Medicare nor the 
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve a power scooter (power operated vehicle).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95870) and continuous 
intraoperative neurophysiology monitoring (G0453) provided on May 12, 2022 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the needle electromyography and continuous intraoperative neurophysiology 
monitoring. The Plan denied your request. The Plan says these services were rendered by a non-network 
provider, and the enrollee was referred by a provider who does not work with the Plan. The Plan also says that 
the enrollee's primary care provider did not refer them for these services.  
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 needle electromyography (95870) and 
continuous intraoperative neurophysiology monitoring (G0453) provided on May 12, 2022 by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for diagnostic testing. You say that you are appealing claim payment denial for 
services rendered on April 26, 2022. The Plan denied your request. The Plan says no authorization was 
obtained prior to testing being completed. 
 
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 diagnostic testing provided on April 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from April 29, 
2022, through May 3, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from April 29, 2022, through May 3, 2022.   
Benefits for these items 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic laboratory services provided on February 8, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic laboratory services. You say that you are appealing the claim denial 
for services rendered on February 8, 2022. The Plan denied your request. The Plan says no authorization was 
obtained prior to services being completed. 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 diagnostic laboratory services provided on 
February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening provided on 
June 29, 2022. 
 
You asked the Plan to pay for the AAA screening. You say that this is the first time you have had an AAA 
screening. You also say in 2019, you had a heart ultrasound, not an abdominal ultrasound. The Plan denied 
your request. The Plan says you are covered for one abdominal aortic aneurysm screening, and you had an 
abdominal aortic aneurysm screening on March 18, 2019. The Plan also says that your benefit for this service 
has been exhausted.  
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. 
 
The test at issue in this appeal, the AAA screening, was requested solely for screening purposes. While your 
plan offers a benefit for this service, it is only allowed once. The record shows that you received an abdominal 
aortic aneurysm screening on March 18, 2019, and this benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening provided on June 29, 2022.