Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum socket system. 
 
You asked the Plan to pre-approve a vacuum socket system. You say that the item is 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 sockets are considered medically necessary and 
reasonable when specific criteria are met. 
 
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 vacuum socket system. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the item is not medically necessary 
per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k), as Medicare does not pay for 
any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or 
to improve the functioning of a malformed body member. The physician documentation does not support that 
you require a vacuum socket suspension system. The request exceeds the your medical need. 
 
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 vacuum socket system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a vacuum socket system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for genetic testing you had on July 14, 2021. 
 
You asked the Plan to waive the coinsurance for the genetic testing services. You say that you would not have 
done this testing if you had known it would be this expensive.  The results were inconclusive and not worth the 
time or money. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for genetic testing.  
 
You have been asked to pay 20% coinsurance for the genetic testing services. This coinsurance applies 
regardless of the results of the testing. 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 genetic testing you 
had on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased out of network on December 12,
2019.
You asked the Plan to pay for out of network hearing aids. You say that the Plan should pay for these hearing
aids. The Plan denied your request. The Plan says out of network hearing aids are not covered.
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 plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased from their preferred vendors. The store purchased from is not a preferred plan vendor.
Therefore, we decided that the Plan does not have to pay for hearing aids purchased out of network on
December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you are due for treatment and need it as soon as possible. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ruxience.
You asked the Plan to pre-approve Ruxience. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Ruxience. Our reviewer says that the medication is medically necessary. Our physician reviewer found the review has determined that the documentation supports that the Ruxience is medically reasonable and necessary. The documentation supports that the Ruxience is safe and effective for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ruxience have been met. Therefore, we decided that the Plan has to pre-approve Ruxience.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance services provided on March 
15, 2021. 
 
You asked the Plan to reduce the copayment for the ambulance services. You say that in 2018 you only paid a 
$125 copayment. 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 $440 
copayment for each ambulance transport.  
 
You have been asked to pay a $440 copayment for the ambulance services. Ambulance services fall within the 
Ambulance 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 reduce the copayment for the ambulance services provided on March 15, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan does not have to pre-approve Yervoy for the enrollee.
You asked the Plan to pre-approve Yervoy. You say that this drug is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria are not met. The QIC overturned the Plans denial. The
Plan requested a reopen and stated that the QIC did not apply the correct criteria.
Our Medical Director looked at the case file. Our Medical Director says that at issue is coverage for Yervoy
(Ipilimumab). The Physician Reviewer determined that the enrollee had disease progression on
Lenvima and his oncologist wanted to try a regimen of Yervoy, Nivolumab, and Ondansetron. The reviewer
determined that the documentation supports that Yervoy was medically reasonable and necessary in this case.
The Plan requested a reopen and stated that subsequent therapy with combination Yervoy (ipilimumab)/Opdivo
(nivolumab) for recurrent hepatocellular carcinoma after prior disease progression on nivolumab and/or
Lenvatinib do not have support in a Medicare-accepted compendia and Medicare-accepted medical journals.
Our Medical Director says that the Plan is correct in this case. The compendia and studies in medical journals
do not support the use of Yervoy (Ipilimumab) and Opdivo (nivolumab) for recurrent hepatocellular carcinoma
after progression on nivolumab. Therefore, Medicare coverage criteria for Yervoy were not met. We looked at
this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules
for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve
Yervoy for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 
10, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you were told that the 
transport would be covered in full. You say that you would not have taken the ride if you knew you had to pay 
this amount. 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 $275 
copayment for each one-way ambulance trip.  
 
You have been asked to pay $252.72, which is less than the $275 copayment for the ambulance transport. Ambulance transport falls within the Ambulance 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 copayment for the ambulance transport provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99203, 99212) and the injections of 
allergenic extracts into the skin (95004, 95024) rendered by the out-of-network (OON) provider from May 20, 
2021, through July 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visits (99203, 99212) and the injections of allergenic extracts into the 
skin (95004, 95024) rendered by the out-of-network (OON) provider from May 20, 2021, through July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary-level referral for a pelvic ultrasound. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says you can be redirected to a community-based provider for diagnostic imaging. 
 
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 referral. Our reviewer says that the 
requested tertiary referral is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no mention in the records of an ectopic pregnancy, which would constitute an emergent 
referral with same day service. The history here is of prior miscarriages. There is no discussion of concern of 
abnormal karyotypical features to make the case for high risk due to congenital abnormalities. In the letter, you 
are distressed about the amount of time or delay to getting the ultrasound done. The in-network provider 
indicates that you have an appointment scheduled. As this time, absent any further information concerning 
elevated risk, a tertiary-level referral 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 the referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary-level referral for a pelvic ultrasound.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) machine you rented from June 1, 2021, to September 1, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP machine. You say that this machine has been 
recalled due to a defect.  You stated that you should not have to pay coinsurance for an item that is not 
working. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the CPAP machine. the CPAP machine falls within the 
durable medical equipment benefit category. Records show that you still have this item in your possession and have not returned it to the supplier.  Because you still have possession of the item, you are responsible for 
coinsurance. 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 the continuous positive airway pressure 
(CPAP) machine you rented from June 1, 2021, to September 1, 2021.  
 
Your complaint about the recall for this CPAP machine is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by either the Plan or the supplier of this equipment. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care billed with a Health 
Insurance Prospective Payment System (HIPPS) code KGSD1 provided from January 21, 2020, to January 31, 
2020. 
 
You asked the Plan to pay for SNF care. You say that this is supported in the records. The Plan denied your 
request. The Plan says the billed HIPPS code cannot be verified because timely assessments were not 
submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that skilled nursing facilities (SNFs) must submit 
assessments according to an assessment schedule.  
 This schedule must include performance of an initial Medicare assessment with an assessment reference date 
that is set for no later than the 8th day of posthospital SNF care, and such other interim payment assessments as 
the SNF determines are necessary to account for changes in patient care needs. Medicare pays a default rate for 
the Federal rate when a SNF fails to comply with the assessment schedule.  
 
We looked at the file and Medicare rules. The submitted medical records do not include assessments performed 
according to the Medicare assessment schedule. 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 pay for skilled 
nursing facility (SNF) care billed with a Health Insurance Prospective Payment System (HIPPS) code KGSD1 
provided from January 21, 2020, to January 31, 2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care, for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the enrollee's therapy notes show they are able to walk thirty (30) feet using a 
walker. The Plan states the enrollee has not had a change in function which would require daily skilled nursing 
or daily therapy needs. The Plan states the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It appears that the plan?s contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision to deny based on no medical necessity. Any 
information that was sent was insufficient because it was not medical records for this enrollee. Therefore, we 
decided that the Plan has to pre-approve SNF care, for the enrollee.  
 
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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke in September 2021 and are living at home with ongoing weakness despite home health physical therapy. Your 
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 youy will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical information does not show that the enrollee's care cannot be provided at a 
lower level. 
 
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.  You were admitted for anemia and gastrointestinal bleeding after recent hemicolectomy for presumed 
malignant mass. 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 medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing of four or more teeth 
per quadrant (D4341) and periodontal scaling and root planing of one to three teeth per quadrant (D4342) 
provided on June 24, 2021. 
 
You asked the Plan to pay for the scalings and planings. You say that the scalings and planings felt like the 
cleaning you used to get from your old provider before they retired. The Plan denied your request. The Plan 
says the services provided were not preventive dental cleanings. The Plan also says that these services 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 pay for the 
periodontal scaling and root planing of four or more teeth per quadrant (D4341) and periodontal scaling and 
root planing of one to three teeth per quadrant (D4342) provided on June 24, 2021.