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

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric stay from July 6, 2022, 
forward. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric stay. You say that the enrollee requires 
continued inpatient psychiatric care. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for a continued inpatient psychiatric admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric stay. 
Our reviewer says that a continued inpatient psychiatric stay from July 6, 2022, forward is not medically 
reasonable and necessary. Our physician reviewer found that this enrollee did not require inpatient mental 
health treatment beyond the dates in question as noted above as he was not a danger to himself or others and 
did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. This 
enrollee was treated under an individualized treatment plan found in the record. It appears that the services 
were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not 
meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 
5, 2022, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal 
or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or 
aggression being cooperative and compliant while not showing any acute threats to safety as the enrollee 
awaited placement. 
 
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 inpatient psychiatric stay have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continued inpatient psychiatric stay from July 6, 2022, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient psychiatric stay from July 12, 
2022, forward. 
 
You asked the Plan to pre-approve a continued inpatient psychiatric stay. You say that the enrollee requires a 
continued inpatient psychiatric stay. The Plan denied your request. The Plan says continued inpatient level of 
care with 24-hour management/monitoring is not indicated to be necessary as of July 12, 2022. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric stay. 
Our reviewer says that a continued inpatient psychiatric stay from July 12, 2022, forward is not medically 
reasonable and necessary. Our physician reviewer found that this enrollee did not require inpatient mental 
health treatment beyond the dates in question as noted above as he was not a danger to himself or others and 
did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. It appears 
that the services were supervised and evaluated by a physician. Based upon review the records provided, this 
enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of July 12, 2022, forward and could have been treated in a lesser restrictive setting as he was not 
showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing 
any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety as 
the enrollee awaited placement. 
 
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 inpatient psychiatric stay have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continued inpatient psychiatric stay from July 12, 2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve bone marrow aspiration. 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. 
 
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 bone marrow aspiration. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found bone marrow aspirate is 
experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance used with a therapeutic CGM 
device (K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that you have an issue with seeing your own 
blood and your fingertips are very sensitive. The Plan denied your request. The Plan says you do not inject 
insulin or use an insulin pump to manage diabetes and therefore do not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the supply allowance used with a therapeutic CGM 
device (K0553).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that you need additional transportation to get 
to your medical appointments, and you feel that 10 rides are not enough for a year. The Plan denied your 
request. The Plan says your benefit covers a maximum of 10 trips per year. Additional trips are not a covered 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab test on March 10, 2022. 
 
You asked the Plan to waive the copayment for lab test. You say that you feel that the plan should cover this 
test and you should not have to pay a copayment. The Plan denied your request. The Plan says the cost-sharing 
you are being charged is correct. 
 
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 $25 
copayment for all other Medicare-covered lab services. Covered services include but are not limited to: 
Laboratory tests. 
 
You have been asked to pay a $25 copayment for lab test. Lab tests fall within the Outpatient diagnostic tests 
and therapeutic services and supplies 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 
lab test on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided by an out-
of-network (OON) provider on February 17, 2022. 
 
You asked the Plan to reduce the copayment for the OON office visit. You say that when you renewed with the 
Plan, the provider showed as in-network. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing 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 $60 
copayment for each specialist visit with an out-of-network (OON) provider.  
 
The file shows that the Plan verified the provider is out-of-network. Therefore, you have been asked to pay a 
$60 copayment for the OON office visit. The OON office visit falls within the Physician/Practitioner Services, 
Including Doctor's 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 reduce the copayment for a 
specialist office visit provided by an out-of-network (OON) provider on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on September 4, 2021. 
 
You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the enrollee was treated twice on this day, and this should be treated as two unrelated claims. The Plan 
denied your request. The Plan says procedure code 99291 has been overturned and procedure code 99053 
remains denied as bundled services are not eligible for separate reimbursement.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on September 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a trigger point injection provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the injection. You say that you were under the impression that 
you would not have any cost. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 $100 
copayment for each outpatient hospital surgery.  
 
You have been asked to pay a $100 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 trigger point injection provided on December 
1, 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 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 is improving but still requires acute care services before transitioning to 
a lower level of care. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis provided to the enrollee on 
January 12, 2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation of lung allograft transplantation. 
 The Plan must follow Medicare rules. Medicare rules say that extracorporeal photopheresis is covered under 
specific conditions. 
 
Castleman's Disease is not a covered benefit for this request. 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 extracorporeal photopheresis provided to the enrollee on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a magnetic resonance imaging (MRI) of 
the heart provided on November 19, 2021. 
 
You asked the Plan to waive the coinsurance for the MRI. You say that you already paid your $30 copayment. 
The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each diagnostic radiology service, including MRIs.  
 
The file shows that the Plan reprocessed the claim to remove the $30 copayment applied to the contrast agent 
injection. Therefore, you have only been asked to pay $219.63, which is 20% of the allowed amount for the 
MRI ($1,098.17 allowed amount x 20% coinsurance = $219.63). The MRI falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for a magnetic resonance imaging (MRI) of the heart provided on November 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from December 28, 2021, to January 25, 2022. 
 
You asked the Plan to waive the copayments for the PT services. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 $30 
copayment for each therapy visit.  
 
The file shows you had 8 visits for PT services from December 28, 2021, to January 25, 2022. You have been 
asked to pay a $30 copayment for each visit, for a total of $240 ($30 copayment x 8 visits = $240). The PT 
services fall within the Outpatient Rehabilitation 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 copayments for physical therapy (PT) services 
provided from December 28, 2021, to January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation, stab phlebectomy, and 
sclerotherapy. 
 
You asked the Plan to pre-approve endovenous ablation, stab phlebectomy, and sclerotherapy. 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. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. 
 
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 endovenous ablation, stab phlebectomy, 
and sclerotherapy. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found in this case, the record indicates that the enrollee has varicose veins. The record does not indicate the 
presence of lower extremity edema, hyperpigmentation, or ulcers. The enrollee has had some response to 
intermittent stocking use. The record does not document failure of conservative therapy. The enrollee has 
saphenous reflux by duplex. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation, stab phlebectomy, and sclerotherapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve endovenous ablation, stab phlebectomy, and 
sclerotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have worn orthotics for heal spurs. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
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.   
 
The records do not show that you 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the office visit. You say that you want to continue to see this provider. The 
Plan denied your request. The Plan says the provider you are requesting to see is out-of-network and there are 
available in-network providers able to provide care for your condition. 
 
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 
an office visit to be provided by an out-of-network provider.