Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says your records received do not indicate you need an intensive therapy program with 
multiple visits from a rehabilitation doctor per week. The Plan states you can safely receive the services you 
need in other settings. For example, a skilled nursing facility, home with home health and home physical 
therapy. 
 
 
 
 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a 
need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the 
enrollee on June 17, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 out of network outpatient mental health care 
provided to the enrollee on June 17, 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. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary The 
Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 only requires short-term additional acute care services that can be 
safely administered at the current facility until 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. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, 
this request for LTACH services will be considered not medically necessary at this time as there would be no 
clinical advantage to transfer at this time. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the SpineFrontier interbody fusion device. 
 
You asked the Plan to pre-approve the SpineFrontier placement. You say that you want to avoid more invasive 
surgery and feel that you should be allowed to pursue this option. The Plan denied your request. The Plan says 
this device is not FDA approved for placement by a pain medicine doctor without performance of 
decompression/fusion surgery. 
 
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 SpineFrontier placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spine frontier interbody fusion device is experimental. More research is 
needed to show safety and efficacy of the device. 
 
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 SpineFrontier placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the SpineFrontier interbody fusion device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the occupational therapy services you 
received on May 5, 2021. 
 
You asked the Plan to waive the deductible for the occupational therapy services. You say that you had home 
health occupational therapy and you're just now receiving the bill.  You do not think you should have to pay 
this amount. The Plan denied your request. The Plan says there was still $61.69 remaining on your deductible 
at the time the claim for these services processed, so you were charged this amount correctly. 
 
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 $500 deductible which applies to outpatient rehabilitation services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which 
applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met 
at the time the occupational therapy services were received on May 5, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for the occupational therapy services you received on May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for outpatient cataract surgery you had on 
May 20, 2021. 
 
You asked the Plan to waive the cost sharing for the outpatient cataract surgery. You say that you were not 
informed that the facility where you had this service was not in-network with the Plan. The Plan denied your 
request. The Plan says although the facility where you had this service is out-of-network, the Plan processed 
this as an in-network claim.  The Plan says that you were charged this cost sharing correctly as you had not met 
your deductible at the time of the services.  After the deductible was satisfied, you were charged the copayment 
appropriately. 
 
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 $750 
deductible, and, once met, a $295 copayment for outpatient surgery.  
 
  
You have been asked to pay a $750 deductible and $295 copayment for the outpatient cataract surgery. You 
had not yet met your deductible when you had this surgery. 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 cost sharing 
for outpatient cataract surgery you had on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve special supplemental benefits. You say that these benefits would be very 
helpful for you and your conditions. The Plan denied your request. The Plan says your provider has indicated 
that you have cardiovascular disorders, but that you do not require intense care coordination and are not high 
risk for hospitalizations or adverse health outcomes. The necessary criteria for the special supplemental 
benefits package are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition. Enrollees must have one or more comorbid and medically complex 
chronic conditions that are life-threatening or significantly limit their health or general functioning. In addition, 
there must be a high risk of hospitalization or other adverse health outcomes; and the enrollee must require 
intensive care coordination.  
 
 We looked at the file and Medicare rules. Your provider indicated on the form provided that you do have a 
qualifying cardiovascular disorder; however, you do not require intensive care coordination and you do not 
have a high risk of hospitalization or other adverse health outcomes. Based on this information, we decided that 
Medicare rules for coverage of special supplemental benefits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services from November 
9, 2021, forward. 
 
You asked the Plan to pre-approve a continued SNF stay You say that continued SNF care is medically 
necessary. The Plan denied your request. The Plan says continued SNF care 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 a continued SNF stay. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found based on the documentation 
provided, the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. At this 
point, the enrollees care needs are custodial and, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continued SNF stay. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) services from November 9, 2021, 
forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CxBladder Detect. 
 
You asked the Plan to pre-approve CxBladder Detect. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered were not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CxBladder Detect have not been met. Therefore, we decided that the Plan does not have to pre-
approve CxBladder Detect.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to provide coverage for a follow care.

You asked the Plan to provide coverage for follow up care. You say that you have had surgery and after caring physical therapy overseen by this provider. You need continued care, and it should be continued by this provider who is familiar with and has guided your treatment. The Plan denied your request. The Plan says that this care is neither urgent or emergent and this provider is out of network.

Medicare rules generally allow plans to restrict enrollees to using plan providers if there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. You have issues in both shoulders. You had issues in one shoulder and physical therapy and based on guidance from your provider will need continued therapy and possibly surgery on the other shoulder. As this provider has started this treatment process with you, it is prudent for you to continue with this provider to ensure continuity of care. Medicare rules for coverage of follow care have been met. Therefore, we decided that the Plan has to provide coverage for a follow care with the physician.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) gingival irrigations (D4921) and an unspecified 
restorative procedure (D2999). 
 
You asked the Plan to pre-approve 4 gingival irrigations and an unspecified restorative procedure. You say that 
you were told that the procedures are not covered by your Plan. You cannot afford the cost. You also say the 
denied procedures must be done prior to the approved procedures so you are asking for reconsideration. The 
Plan denied your request. The Plan says the services are not covered under your plan. Any services not listed 
are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
(4) gingival irrigations (D4921) and an unspecified restorative procedure (D2999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 12, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that the services you received should 
not warrant a copayment because the provider did nothing to help you. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for specialist visits.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctors 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. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on July 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on August 19, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the personnel at 
the clinic said they were calling an ambulance and three times you told them not to call. You say that you 
should not be charged when you refused the services. The Plan denied your request. The Plan says according to 
Medicare, the ambulance benefit is a transportation benefit. If no transport occurs, this is not considered to be a 
Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 19, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interlaminar lumbar injections to be rendered by the 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested 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 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 providers in this case are not networks provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve  
interlaminar lumbar injections to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0813). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need this because you are not able to 
walk. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a manual wheelchair. The submitted medical records 
show that your physician recommended and ordered a manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair (K0813).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit provided on May 1, 2021.

You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says the member was enrolled in Hospice on this date of service. The claim must be billed to Original Medicare as the Plan is no longer the primary insurance carrier.

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 an emergency department visit provided on May 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital bed provided to the enrollee on April 28, 2021. 
 
You asked the Plan to pay for the bed. You say that this should be paid for. The Plan denied your request. The 
Plan says it cannot be determined if a physician's order was given. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for durable 
medical equipment to be covered. 
 
The documentation submitted did not include a physician order. Based on this information, we decided that 
Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to 
pay for a hospital bed provided to the enrollee on April 28, 2021.