Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 You asked the Plan to pre-approve the SNF admission. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says the enrollee is medically stable and is at moderate assistance for med 
mobility and mechanical assistance for transfers. The Plan says that the enrollee's needs can safely be received 
at a different setting. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 53-yr-old male with 
a medical history including end-stage renal disease on hemodialysis, diabetes mellitus and a femur fracture in 
October 2021 who was admitted to the hospital due to weakness and lower extremity pain. He was diagnosed 
with a non-union of the left femur fracture. There were no acute orthopedic issues. A bone stimulator was 
ordered. The most recent therapy documentation indicates the enrollee is unable to ambulate and requires 
assistance with transfers and bed mobility. The documentation indicates he is at his functional baseline. 
 
The enrollee has stabilized medically and is ready for discharge from the hospital.  The member does not 
require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive 
further rehab services at a lower level of care. Although further rehab services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a 
skilled nursing 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you only spoke on 
the phone for 5 minutes, and you feel there should be no copayment for this. 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 $45 
copayment for each visit with a specialist, including telehealth services.  
 
You have been asked to pay a $45 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Physician/Practitioner Services, Including Doctor's 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 telehealth visit provided on December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee arthroscopy with meniscectomy and 
chondroplasty. 
 
You asked the Plan to pre-approve the requested knee arthroscopy. You say that you believe that this surgery 
would be beneficial. The Plan denied your request. The Plan says the submitted documentation and current 
literature do not support that arthroscopic meniscectomy and chondroplasty is the appropriate procedure for a 
knee with severe osteoarthritis. 
 
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 requested knee arthroscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this 69-year-old male was being treated for a complex tear of the medial 
meniscal, left knee; complex tear of the lateral meniscus, left knee; effusion, left knee; unilateral primary 
osteoarthritis, left knee. He presented with left knee pain that has not changed. The exam of the left knee 
reveals positive varus deformity. McMurrays is positive. There is medial and lateral joint line pain.  
 However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, there is imaging evidence of severe 
osteoarthritis in the left knee. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested left arthroscopic meniscectomy and chondroplasty, in this case, is not medically reasonable or 
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 requested knee arthroscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a left knee arthroscopy with meniscectomy and chondroplasty.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a knee replacement procedure and 
physical therapy (PT) services provided from September 9, 2021, to September 10, 2021. 
 
You asked the Plan to waive the copayments for the knee replacement and PT services. You say that this was 
supposed to be an inpatient stay. 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 $400 
copayment per visit for outpatient surgery. Your contract with the Plan also clearly says that you must pay a $40 copayment for each therapy visit. 
 
The file does not show evidence of an inpatient order written for your procedure. Therefore, you have been 
asked to pay a $400 copayment for the knee replacement. The knee replacement falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. You have also been asked to pay a $40 copayment for the PT services. The PT services fall within the 
Outpatient Rehabilitation Services benefit category. The total for the visit is $440. 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 copayments for a knee replacement procedure and physical therapy (PT) services provided from 
September 9, 2021, to September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and bitewings (D0274) provided by an out-of-network provider on December 28, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation, prophylaxis, and bitewings. You say that you 
were told that your insurance would stay the same. The Plan denied your request. The Plan says services 
provided by an out-of-network provider 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 Plans coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation, prophylaxis, and bitewings when the services are provided by a participating 
provider. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation, prophylaxis, and bitewings have not been met. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), 
and bitewings (D0274) provided by an out-of-network provider on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP appliance provided on December 9, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for CPAP appliance. You say that you would like the plan to cover the CPAP 
appliance in the same manner the CPAP machine would be covered. The Plan denied your request. The Plan 
says the provider is not under contract with the health plan and is not certified with Medicare. 
 
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 CPAP appliance provided on December 9, 2021 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital observation provided on July 17, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital observation. You say that the provider billed incorrectly, 
and they never resubmitted the fixed claim. The Plan denied your request. The Plan says the rendering provider 
is an out-of-network provider and there was no approved authorization for the services submitted on the claim. 
 
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 the outpatient hospital observation provided on 
July 17, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass lenses (V2201) purchased December 7, 2021. 
 You asked the Plan to pay for the lenses. You say that the office manager told you that you could use your 
benefit on this date. The Plan denied your request. The Plan says you have already used your vision benefit for 
the 2021 calendar year; therefore, this service is denied. 
 
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 these services up to $120 once per calendar year. 
 
We looked at the file and the Plan's rules. The documentation shows that you previously used your vision 
benefit on February 4, 2021. Therefore, your benefit for routine eyewear was exhausted for the 2021 calendar 
year on the date in question. Based on this information, we decided that the Plan's rules for coverage of the 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass lenses 
(V2201) purchased December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary given the presence of 
chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in Intelligent Volume Assured Pressure Support (iVAPS) mode with or without 
Auto-EPAP (AE) that could be delivered by bilateral positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has chronic obstructive pulmonary disease (COPD) with recent exacerbation, but there is no documentation of chronic C02 retention with an arterial blood gas study (ABG) while stable as an outpatient. There is a diagnosis 
of obstructive sleep apnea, but there is no indication in the records of whether this is being treated. The AVAPS 
mode of support that has been ordered can be delivered via BiPAP, and Medicare does not cover a ventilator 
when used as BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services provided to the enrollee on May 29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that there was no recorded emergency or urgency. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found the record 
indicates that the enrollee was admitted with shortness of breath due to dilated cardiomyopathy and aortic 
stenosis. The record indicates that the enrollee was confused and required supplemental oxygen and 
intravenous benzodiazepine in route. The record indicates that the enrollee required a higher level of cardiology 
care than was available at the sending facility. The travelled distance precluded ground transportation. The 
elements of the coverage criteria are satisfied. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
air ambulance services provided to the enrollee on May 29, 2021.  
 
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 pay for a crown (D2750) provided by a participating provider on 
January 10, 2022. 
 
You asked the Plan to pay for a crown. You say that you were unaware that your referral was no longer good. 
You say that because of Covid-19 you were unable to get the crown sooner. The Plan denied your request. The 
Plan says D2750 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2750) provided by a participating provider on January 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the clinical documentation supports the need for 
SNF care. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (32555) provided November 4, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 32555 is not supported in the medical record. Specifically, the code was not billed with 
a required global surgery modifier to denote a separate unrelated service. 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 pay for surgical services (32555) provided November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Contour Next Test Strips. 
 
You asked the Plan to pre-approve the strips. You say that the strips are necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet the criteria for coverage under Part B for a non-preferred 
diabetic supply bought at a pharmacy. 
 
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 the strips. Our physician reviewer 
found standard of care or to use the contour next strips with the enrollee's pump as they are linked. Although 
technically EH could enter in the BG from another meter each time, this would likely compromise the 
enrollee's care and would not meet standard of care and hence, the requested brand should be provided. 
 
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 strips have been met. Therefore, we decided that the Plan has to pre-approve 
Contour Next Test Strips.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Diagnostic Radiology Procedure provided on July 13, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Diagnostic Radiology Procedure. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network office 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 Diagnostic Radiology Procedure provided on July 
13, 2021 by an out-of-network (OON) provider.