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

 
We decided that the Plan does not have to waive the copayment for Inpatient Hospital care from August 24, 
2021 to September 9, 2021. 
 
You asked the Plan to waive the copayment for Inpatient Hospital. You say that you feel that you were billed 
for two copays and that it should only have been one. The Plan denied your request. The Plan says 5he 
copayment applied was 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 $385 
copayment each day, day(s) 1-5 and a $0 copayment for days 6+ for Inpatient Hospital care. At the time the 
claim was processed, you had $1,226.07 remaining to meet your 2021 out of pocket maximum. Therefore, you 
are responsible for $1,226.07 and the claim processed correctly. 
 
You have been asked to pay a $385 copayment each day, day(s) 1-5 and a $0 copayment for days 6+ for 
Inpatient Hospital care. Inpatient Hospital care falls within the Inpatient hospital 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 Inpatient Hospital care from August 24, 2021 to September 
9, 2021.
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 has been in the hospital for longer 
because he is not mobilizing, which is leading to bed sores. You say that the hospital is not a proper treatment 
setting and the enrollee requires aggressive rehabilitation. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services 
needed in other settings. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for Parkinson's disease and recurrent falls. The enrollee's medical problems are stable. There are 
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) purchased on November 10, 2021. 
 
You asked the Plan to pay for hearing aid. You say that your benefits page shows that you have in-network and 
out-of-network benefits for hearing aids, and you feel you should be reimbursed for this item. The Plan denied 
your request. The Plan says the supplemental hearing benefit is only available through the Plan's specified 
routine vendor network. Hearing aids purchased through other vendors are not covered by your plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are the specific models/brand listed by the Plan and purchased through the 
specified routine hearing vendor.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified routine 
hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of hearing aid 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261) 
purchased on November 10, 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 if the enrollee does not receive therapy 
soon, he may have a reduced clinical outcome in the long run. You say that the enrollee needs care in an 
LTACH in order to regain function. The Plan denied your request. The Plan says that the guidelines for 
coverage have not been met. The Plan says that the enrollee can safely receive the care needed in the current 
hospital setting. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. 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.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zytiga. 
 
You asked the Plan to pre-approve Zytiga. You say that the records provided support the need for the drug 
being requested. The Plan denied your request. The Plan says the enrollee does not have pharmacy benefits 
through them. The Plan says that the enrollee does have Verizon, which provides its own pharmacy benefits. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zytiga.  
 Benefits for Zytiga 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: 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 you are not safe to return home and feel you need to 
be transferred to an IRF in order to continue your recovery. The Plan denied your request. The Plan says the 
criteria for admission to an IRF are not met. Your therapy needs can be provided at home or intermittently at a 
long-term care facility. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that your doctor recommended 12-24 physical 
therapy sessions, but you have only had four so far. You feel you will not recover or be able to operate fully 
without this therapy. The Plan denied your request. The Plan says the requested physical therapy is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition. You have had prior electrical stimulation and 
nutripharmaceutical blend injections in the lower extremities and the documentation does not reveal that you 
require the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can only be safely and effectively performed by a therapist, or by or under the supervision of a 
therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. In addition, the documentation does not 
reveal a clear etiology of your lower extremity symptoms. The requested additional treatment is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve eight (8) additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom, myoelecteric elbow-wrist-hand-finger 
orthosis (MyoPro). 
 
You asked the Plan to pre-approve the MyoPro. You say that you would like reconsideration because the 
requested MyoPro is medically necessary. The Plan denied your request. The Plan says this orthosis is not 
furnished in accordance with accepted standard of medical/rehabilitative practice for the treatment of long term 
muscle weakness post stroke. 
 
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 MyoPro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards 
and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use 
based on scientific evidence.  
 
 There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes 
for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence 
in the literature that this device will increase participation in bimanual activities. 
 
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 MyoPro have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the custom, myoelecteric elbow-wrist-hand-finger orthosis (MyoPro).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert system. 
 
You asked the Plan to pre-approve the requested system. You say that this system is part of what you need. The 
Plan denied your request. The Plan says the item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Life Alert system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arformoterol Tartrate (J7605). 
 
You asked the Plan to pre-approve Arformoterol Tartrate. You say that this is medically necessary. The Plan 
denied your request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Arformoterol Tartrate. Our reviewer 
says that the requirements for coverage of Arformoterol Tartrate have not been met. Our physician reviewer 
found the Plan requires a trial of Perforomist (formoterol) before they will approve the requested drug. The 
records do not show that the enrollee has tried this drug, that this drug would likely be less effective, or that this 
drug would have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Arformoterol Tartrate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Arformoterol Tartrate (J7605).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D Biopsy (88361, 88312, 88305, 88104) 
provided on September 7, 2021. 
 
You asked the Plan to pay for the WATS 3D Biopsy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this testing was 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 pay for the WATS 3D Biopsy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee underwent upper endoscopy for a history of gastroesophageal reflux.  The literature does not support the safety and efficacy of the requested service, as 
defined by Medicare rules, for the enrollee's clinical condition.  The American Society of Gastrointestinal 
Endoscopy has given the requested service a conditional recommendation for the noted use with low quality of 
evidence, insufficient to establish the safety and efficacy of the requested service, as defined by Medicare rules, 
for the enrollee's clinical condition. 
 
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 WATS 3D Biopsy have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS 3D Biopsy (88361, 88312, 88305, 88104) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on October 19, 2021. 
 
You asked the Plan to pay for an office visit. You say that you have submitted medical records. You also say 
the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 
until the Plan gets the primary evidence of benefits (EOB). 
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for an office visit until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for an office visit (99214) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation services 
provided from January 25, 2021, to January 28, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. You say that you disagree with 
the charges. The Plan denied your request. The Plan says the copayment applied was 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 $225 
copayment for outpatient hospital observation services.  
 
You have been asked to pay a $225 copayment for outpatient hospital observation. Outpatient hospital 
observation falls within the Outpatient Hospital Observation 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 outpatient hospital observation services 
provided from January 25, 2021, to January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial dentures. 
 
You asked the Plan to pre-approve partial dentures. You say that the dentures that were made for you were not 
made well. You say that you have had many problems with them including scrapes, cuts, and bleeding. You 
say that you had these dentures adjusted and they continued to cut your gums. You say that you are a diabetic 
and wounds do not heal quickly. You say that you need new dentures so that you can eat well. The Plan denied 
your request. The Plan says the benefit for dentures is exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for dentures is limited to 
once every 5 years. The records show that you received coverage for a set of dentures in February of 2021. 
This means that your benefit for dentures is currently exhausted. Therefore, we decided that the Plan does not 
have to pre-approve partial dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that a reasonable trial with the basic pump had been tried 
prior to ordering the segmented pump. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there has not been a trial with the basic pump which is required by Medicare. The review has determined 
that the enrollee does not have lymphedema of the chest, trunk, or abdomen. The enrollee does not have unique 
characteristics that would indicate the segmented pump over a standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.