Persius/hicric huggingface dataset:
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 LTACH is medically necessary, and 
that the enrollee exceeds the requirements for LTACH. The Plan denied your request. The Plan says the 
LTACH is not medically necessary, and the enrollee's needs can be met at another setting such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
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 was admitted to an acute inpatient hospital for a myocardial infarction. 
The enrollee is status post a Coronary Artery Bypass Graft x3. She has a perioperative stroke and a 
postoperative cardiac arrest with subsequent hypoxic encephalopathy. She is also status post a tracheostomy 
and remains on a ventilator. There is no documentation that the enrollee is capable of being weaned at this 
time. There is no documentation that the enrollee will benefit from and improve with LTACH management. 
The enrollee is receiving appropriate care at the present acute care hospital.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization 
(37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested services are 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 pre-approve the surgical services. Our reviewer says 
that the requested surgical services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee has some degree of peripheral 
vascular disease, however there is no claudication. The reviewer found that the documentation does not 
confirm that the arterial narrowings on the imaging are causing any symptoms. Therefore, the reviewer found 
that there is insufficient documentation to support the medical necessity for lower extremity angiography and revascularization of lower extremity arteries in this case. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lower extremity angiography and revascularization (37224, 37225, 37226, 37227, 
37228, 37229, 37230, 37231).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide provided on October 28, 2021. 
 
You asked the Plan to pay for a stair glide. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide provided on October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 22, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
 
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 testing provided on June 22, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial for IRF care. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of IRF care have been met. The Plan has 
made multiple attempts to obtain medical records from the provider. Therefore, we decided that the Plan does 
not have to pre-approve IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out of network therapy visit provided 
from April 19, 2022, to July 5, 2022. 
 
You asked the Plan to waive the coinsurance for an out of network therapy visit. You say that you are very 
disappointed with this plan and feel like you were blind-sided. You did not know your provider was out of 
network with such a high coinsurance. The Plan denied your request. The Plan says this cost sharing was 
charged 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 50% 
coinsurance for outpatient mental health care ($790 x 50% = $395).  
 
You have been asked to pay a $395 total coinsurance for an out of network therapy visit(s). This item/service 
falls within the outpatient mental health 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 coinsurance 
for an out of network therapy visit provided from April 19, 2022, to July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided on 
January 5, 2022, to July 5, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you are requesting 
reconsideration stating you had this machine over 10 years and just started getting bills for it. The Plan denied 
your request. The Plan says this cost sharing was charged 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 provider. The allowed amounts of these durable medical equipment 
total $5,407.50, resulting in a total coinsurance amount of $1,081.50. 
 
You have been asked to pay 20% coinsurance for durable medical equipment. This item/service falls within the 
durable medical equipment provider 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 
durable medical equipment provided on January 5, 2022, to July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are having surgery soon and need the 
shower chair for assistance. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 24, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless they are authorized by the Plan before the 
services are provided. 
 
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 
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 subsequent nursing facility care provided on March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on December 03, 2020. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for each Medicare-covered one-way trip via ground ambulance. Covered ambulance services 
include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can 
provide care only if they are furnished to a member whose medical condition is such that other means of 
transportation could endanger the persons health or if authorized by the plan. 
 
You have been asked to pay a $250 copayment for ambulance. This item/service 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 ambulance on December 
03, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day reader. 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 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14-day reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14-day reader.
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's medical management and rehabilitation 
needs require an inpatient rehabilitation stay with close physician supervision. The Plan denied your request. 
The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of 
care such as at home with supervision and home health services, or in an assisted living facility with home 
health services. 
 
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 was admitted for compression fracture and respiratory failure. The 
enrollee's medical problems are stable, and 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 medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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 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 hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new power wheelchair with accessories. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The information we received shows 
that you have a brand-new wheelchair, but you require a new battery. The request for a new power wheelchair 
with accessories is not appropriate because this power wheelchair is still within the 5-year RUL and the 
documentation submitted does not show that the wheelchairs is irreparably worn, irreparably damaged, or that 
you had a change in medical condition to warrant the new power wheelchair at issue. However, you should send a request to the Plan for a new battery. Therefore, we decided that the Plan does not have to pre-approve a 
new power wheelchair with accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a radiation therapy visit provided on 
February 17, 2022. 
 
You asked the Plan to waive the coinsurance for a radiation therapy visit. You say that your maximum out-of-
pocket had already been met and you should not owe anything. The Plan denied your request. The Plan says 
this cost sharing was charged 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 Medicare-covered therapeutic radiology services.  
 
 
  You have been asked to pay a coinsurance of $355.47, which is 20% of the allowed amount for a radiation 
therapy visit ($1,777.36 allowed x 20% = $355.47). However, you met your maximum out-of-pocket during 
processing of the claim and only assessed a total coinsurance of $352.58. This item/service 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 radiation therapy visit provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (intraosseous basivertebral 
nerve ablation). 
 
You asked the Plan to pre-approve Intracept. You say that this is medically necessary and supported by strong 
science. The Plan denied your request. The Plan says there is insufficient evidence of the efficacy of this 
procedure. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure 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 Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure (intraosseous basivertebral nerve ablation).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for an office visit and 
transvaginal ultrasounds provided from April 16, 2021, to May 17, 2022. 
 
You asked the Plan to waive the deductible and copayment for the office visit and ultrasounds. You say that 
you feel the coding and charges are incorrect. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible which applies to certain items and services in 2021. 
 
Your contract with the Plan also says that there is a $10 copayment for each visit with your PCP. 
 
Your contract with the Plan also says that there is a $10 copayment after the deductible is met for diagnostic 
procedures and tests. 
 
Your contract with the Plan also says that there is a $450 deductible which applies to certain items and services 
in 2022. 
 
The items or services you asked the Plan to waive the deductible and copayment for fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is $300 deductible which applies to certain items and services in 
2021. There is also a $10 copayment for the PCP office visit and a $10 copayment for the ultrasound provided 
on April 16, 2021. There is also a $450 deductible which applies to certain items and services in 2022. This 
cost sharing is a contractual obligation that had not been met at the time the office visit and ultrasounds were 
received on April 16, 2022, to May 17, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible and copayment for an office visit and transvaginal ultrasounds provided from April 16, 2021, to 
May 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Farxiga tablet. 
 
You asked the Plan to pre-approve Farxiga. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Farxiga 
tablet.  
 Benefits for Farxiga may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.