Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 7, 2022, to January 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy provided on January 7, 2022, to 
January 28, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83615, 80061, 36415, 80076, 83036) provided 
on January 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that the services rendered to the enrollee should be 
processed and paid for as out-of-network. The Plan denied your request. The Plan says a prior authorization 
was not obtained before the enrollee received the lab services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services (83615, 80061, 36415, 80076, 83036) 
provided on January 25, 2022, by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 enrollee is non-weight bearing and non-ambulatory. The enrollee has limited 
capacity for rehabilitation and does not require intensive rehabilitation. The enrollee is continent, has no 
neurological injury and does not require frequent physiatry oversight. The treating physician notes the enrollee 
is awaiting skilled nursing facility transfer. The enrollee's condition can reasonably be met 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 failure to thrive with concomitant depression is not an IRF compliant diagnosis and 
clinical documentation does not show why the enrollee would require close physician monitoring by a 
rehabilitation physician on an inpatient basis that specializes in rehabilitation. An enrollee with adult failure to 
thrive and depression would not be expected to make significant functional gains with intense therapy as that is 
not clinically recognized treatment of primary diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit on January 4, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you cannot afford to pay this. 
The Plan denied your request. The Plan says the cost share has been applied 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 a $25 
copayment for services obtained from an in-network specialist.  
 
You have been asked to pay $21.74 for a specialist visit. Your contract with the Plan clearly states you must 
pay a $25 copayment for a specialist visit. However, you have only been asked to pay $21.74 which is less than 
the copayment amount. 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 on January 
4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically 
necessary. 
 
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 found to be medically reasonable and necessary. Our physician reviewer found the 
clinical documentation shows that you have active medical health conditions and would benefit from close 
medical supervision on an inpatient basis. Evaluating therapists document that you require and would tolerate 
both intense physical therapy and occupational therapy thus IRF criteria have been met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 a reinstatement of the enrollee's 2022 vision benefits. 
 
You asked the Plan to pre-approve a reinstatement of the enrollee's 2022 vision benefits. The Plan denied your 
request. The Plan says the enrollee has exhausted their vision benefit for the 2022 plan year. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam per year and one pair of eyeglasses per year. 
 
We looked at the file and the Plan's rules. The record shows that the enrollee received an eye exam and glasses 
in May of 2022, exhausting their benefits. The contract also clearly states that replacement lenses and frames 
are not covered. Based on this information, we decided that the Plan's rules for coverage of a reinstatement of 
the enrollee's 2022 vision benefits have not been met. Therefore, we decided that the Plan does not have to pre-
approve a reinstatement of the enrollee's 2022 vision benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultraviolet phototherapy system for home use. 
 
You asked the Plan to pre-approve the ultraviolet phototherapy system. You say that it is medically necessary 
for the enrollee to have this equipment in their home. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a home ultraviolet phototherapy system is for 
patients with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. In this case, the enrollee does not have a diagnosis of generalized 
intractable psoriasis. Based on this information, we decided that Medicare rules for coverage of the ultraviolet 
phototherapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
ultraviolet phototherapy system for home use.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99219) and observation care 
discharge day management (99217) provided on March 1, 2022, and March 2, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the initial observation care and discharge day management. You say that these 
services were medically necessary. The Plan denied your request. The Plan says these services were rendered 
by a non-network provider. The Plan also says that these services are not urgent or emergent, nor were they 
approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the initial observation care (99219) and 
observation care discharge day management (99217) provided on March 1, 2022, and March 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on December 30, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit provided on 
December 30, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis with a K3 foot. 
 
You asked the Plan to pre-approve the prosthetic foot. You say that this prosthesis is medically necessary. The 
Plan denied your request. The Plan says the requested foot exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities. 
 
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 prosthetic foot. Our reviewer says 
that the requested prosthesis is not medically necessary. Our physician reviewer found the provided records do 
not include any clinical documentation from the enrollee's treating provider supporting that she is a K3 level 
ambulator. 
 
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 prosthetic foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lower limb prosthesis with a K3 foot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair or nonroutine service for durable medical 
equipment (DME) (K0739, E2370). 
 
You asked the Plan to pre-approve repair of a scooter. You say that you are requesting reconsideration for the 
repairs of the enrollee's scooter. The Plan denied your request. The Plan says the request does not meet the 
Medicare or plan coverage criteria. It is less expensive to replace the scooter than to repair it. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollees scooter was purchased in 
December 2017. The records also show that the enrollee has received repairs of her scooter totaling $1,896. 
The replacement cost of the scooter is $1,224. The cost to fix your scooter must be much less than the cost of a 
new scooter, therefore, the request for repairs cannot be approved. Based on this information, we decided that 
Medicare rules for coverage of repair of a scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve repair or nonroutine service for durable medical equipment (DME) (K0739, E2370).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 enrollee is functioning at a community level and does not require intensive 
rehabilitation. The enrollee's own performance shows he has good reserves and is able to improve rapidly with 
a low level of rehabilitation service provided during an acute stay. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insertion of interlaminar/interspinous process 
stabilization/distraction device (Vertiflex device). 
 
You asked the Plan to pre-approve Vertiflex device. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the 
 
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 Vertiflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of radiculopathy and arthritis of the small joints of the back. The 
enrollee has a six-year history of low back pain after bending down and lifting frequently. Interlaminar spacer 
devices are experimental in spinal surgery. More research is needed. Therefore, the enrollee does not meet 
criteria for the requested services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device (Vertiflex 
device).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 4, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you should not be responsible 
to pay this. The Plan denied your request. The Plan says the cost share has been applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $10 copayment for other Medicare-covered laboratory tests that are not FIT tests.  
 
The enrollee has been asked to pay $10 for laboratory services. Laboratory services fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for laboratory services provided on April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix Air kit. 
 
You asked the Plan to pre-approve True Metrix Air kit. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the requested item 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of True Metrix Air kit have not been met. Specifically, the requested item is a non-preferred brand. 
The case record does not contain medical documentation to support the medical necessity of the requested item. 
Therefore, we decided that the Plan does not have to pre-approve True Metrix Air kit.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 you do not require the intensity of rehabilitation physician oversight provided in the 
acute inpatient rehabilitation setting. Your medical and rehabilitation needs do not require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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.