Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital observation care services provided on 
May 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent hospital observation care. You say that there is no authorization or 
referral needed when seen under the place of service 22. The Plan denied your request. The Plan says the 
member received services from an out-of-network outpatient hospital on May 26, 2022. The Plan also says that 
the services rendered did not have 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 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 subsequent hospital observation care services 
provided on May 26, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the knee brace provided on April 01, 
2022. 
 
You asked the Plan to waive the coinsurance for the knee brace. You say that you never used the device and 
you feel you shouldnt have to pay. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the knee brace. This item/service falls within the prosthetic 
devices and related 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 the knee 
brace provided on April 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the huntingtin gene analysis testing provided on January 27, 
2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the test is non-
covered by Medicare. 
 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 test at issue is unlikely to impact therapeutic decision making. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the huntingtin gene analysis testing provided 
on January 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CTA provided on April 6, 2022. 
 
You asked the Plan to waive the copayment for CTA. You say that you should not be responsible to pay this. 
The Plan denied your request. The Plan says that 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 $180 
copayment for advanced imaging services.  
 
You have been asked to pay a $180 copayment for CTA. CTA 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 copayment for 
CTA provided on April 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 17, 
2022, to March 10, 2022. 
 
You asked the Plan to pay for the home health care services. You say that you would like this decision to be re-
evaluated. The Plan denied your request. The Plan says the non-contracted provider did not submit the Request 
for Anticipated Payment (RAP) claim for services for dates of service January 17, 2022, to March 10, 2022, 
until March 25, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit an NOA to their Medicare 
contractor within 5 calendar days after the start of care date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the NOA was 
not submitted within 5 calendar days from the start of care date. Therefore, we decided that the Plan does not 
have to pay for the home health care services provided from January 17, 2022, to March 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care on June 30, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you should not be responsible to pay 
this because you were told you were not well enough to be discharged and you were not told you were going to 
have to pay a copayment. The Plan denied your request. The Plan says the cost share was 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 $188 
copayment for days 21 through 100 for skilled nursing facility care.  
 
You have been asked to pay a $188 copayment for SNF care. SNF care falls within the Skilled Nursing Facility 
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 SNF care on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computed Tomography provided on March 
29, 2022, to April 29, 2022. 
 
You asked the Plan to waive the copayment for Computed Tomography. You say that you were told the Plan 
would cover the copayment. You cannot afford this and would not have had this test done if you had known 
how much it would cost. 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 $375 
copayment for outpatient hospital services. 
 
You have been asked to pay a $375 copayment for Computed Tomography. This item/service falls within the 
outpatient hospital 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. You had two CT scans, therefore, you owe $750 ($350 x 2 = $750). Therefore, we decided 
that the Plan does not have to waive the copayment for Computed Tomography provided on March 29, 2022, to 
April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on April 15, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and x-rays provided on March 24, 2022, by an 
OON provider. 
 
You asked the Plan to pay for an office visit and x-rays. You say that you are appealing claim payment for the 
services rendered. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 
 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 an office visit and x-rays provided on March 24, 
2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
tried and failed the preferred agent. 
 
 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 Evenity. Our physician reviewer found 
that the enrollee has age-related osteoporosis without current pathological fracture. The Plan requires a trial of 
Forteo before they will approve the requested drug. The case file does not contain documentation of trial and 
failure of Forteo. The documentation does not support that Forteo would likely be less effective or would likely 
have adverse effects for the enrollee 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on May 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be paid. 
The Plan denied your request. The Plan says the claim denied correctly. 
 
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 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 office visit (99204) provided on May 27, 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 inpatient psychiatric admission from July 21, 2022, to 
present. 
 
You asked the Plan to pre-approve inpatient psychiatric admission from July 21, 2022, to present. You say that 
the requested inpatient psychiatric admission from July 21, 2022, to present is medically necessary. The Plan 
denied your request. The Plan says the requested inpatient psychiatric admission from July 21, 2022, to present 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric admission from 
July 21, 2022, to present. Our reviewer says that the requested inpatient psychiatric admission from July 21, 
2022, to present is not medically necessary. Our physician reviewer found this enrollee did not appear to 
require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and 
compliant. It did not appear that active treatment was taking place. It did not appear that the services were 
reasonably expected to improve the enrollees condition or for the purpose of diagnosis. I am unable to find an 
individualized treatment plan however the entire record is not present. It did appear that the records were 
supervised and evaluated by a physician. Based upon review of the records provided, the admission of this 
enrollee does not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a 
danger to himself or others and had no auditory or visual hallucinations. He is noted to be cooperative and 
compliant with treatment while not showing any aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric admission from July 21, 2022, to present have not been 
met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission from 
July 21, 2022, to present.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that you do not meet the Medicare criteria for a CGM. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 CGM. Our reviewer says that you meet 
the Medicare criteria for the requested CGM. Our physician reviewer found you have diabetes, use 3 or more 
daily injections of insulin, have been performing tests 4 or more times per day, and your insulin regimen 
requires frequent adjustment based on test results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CGM have been met. Therefore, we decided that the Plan has to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided from July 28, 
2021, to July 31, 2021. 
 
You asked the Plan to pay for the (PT) services. You say that the enrollee had revoked their hospice benefit 
prior to the dates of service in this case. The Plan denied your request. The Plan says the enrollees claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 21, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) 
services provided from July 28, 2021, to July 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds Medicare guidelines 
for an LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, the long 
term acute care hospital services you are requesting do not meet the requirements for approval. 
 
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 the acute care hospital for a coronary artery bypass graft 
surgery complicated by poor pulmonary toilet and acidosis requiring reintubation two more times after failed 
attempts to extubate. The enrollee was treated with diuresis. Trach and percutaneous endoscopic gastrostomy 
were placed. Recent notes describe the enrollee, as now tolerating low dose oxygen to room air trials via trach 
mask and is medically stable.  
 
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can safely be administered at the current facility until more stable and appropriate for a lower 
level of care. The enrollee does not require services at the LTACH that are not available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health office visit provided on May 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the behavioral health office visit. You say that you were told the provider was in-
network. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
behavioral health office visit. We found no exception that would require the Plan to pay for the behavioral 
health office visit. The records provided for review do not show that the behavioral health office visit was 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the behavioral health office 
visit provided on May 10, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
September 24, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that the continued admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the requested continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee does not require continued skilled nursing or therapy 
services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care after September 24, 2022.