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

 
We decided that the Plan does not have waive the $206.97 coinsurance for outpatient surgery performed from 
March 2, 2022, to March 8, 2022. 
 
You asked the Plan waive the $206.97 coinsurance for outpatient surgery performed from March 2, 2022, to 
March 8, 2022. You say that you are on a fixed income and cannot afford to pay this amount. The Plan denied 
your request. The Plan says you are responsible to pay a 40% coinsurance for out-of-network surgery services 
furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any 
other location. 
 
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 40% 
coinsurance for out-of-network outpatient surgery performed by a physician. The allowed amounts of these 
claims total $517.39, resulting in a coinsurance amount of $206.97 
 
You have been asked to pay a 40% coinsurance for outpatient surgery performed from March 2, 2022, to 
March 8, 2022. Outpatient surgery 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 waive the $206.97 coinsurance for outpatient surgery 
performed from March 2, 2022, to March 8, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that IRF care is not medically necessary and the enrollee does not have intensive or 
specialized rehabilitation needs. 
 
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 for this enrollee. Our physician reviewer 
found records show that the enrollee has very complex medical management needs and IRF criteria has been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that additional routine 
transportation trips are medically necessary. The Plan denied your request. The Plan says the benefit does not 
provide coverage for more than 20 one-way trips no matter the circumstances. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $250 copayment for outpatient surgery performed on 
January 13, 2022. 
 
You asked the Plan to waive the $250 copayment for outpatient surgery performed on January 13, 2022. You 
say that you cannot afford to pay this amount. The Plan denied your request. The Plan says you are responsible 
to pay a $250 copayment per day for outpatient surgery performed in an outpatient hospital or ambulatory 
surgical center. 
 
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 Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $250 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers. 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 $250 copayment for outpatient surgery 
performed on January 13, 2022.
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 enrollee clearing exceeds the CMS 
criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says authorization 
denied because the LTACH is not medically necessary, and the enrollee can continue to stay at the acute 
hospital stay until the member can discharge to a lower level of 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 appears to be more stable and improving and should only require short-
term additional acute care services that can be safely completed at the current facility until appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prodigy no coding test strips. 
 
You asked the Plan to pre-approve Prodigy no coding test strips. You say that the enrollee will be running out 
of supplies. The Plan denied your request. The Plan says the requested blood glucose testing item/system is not 
one of the Plan's preferred Part B systems. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage organizations may limit 
coverage to certain Durable Medical Equipment (DME) brands, items, and supplies.  
  
We looked at the file and Medicare rules. The Plan requires the use of blood glucose monitors and test strips 
that are ACCU-CHEK manufactured by Roche, or Trividia products. Therefore, we decided that the Plan does 
not have to pre-approve Prodigy no coding test strips.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have any complex or intensive rehabilitation needs. The 
enrollee needs to walk as tolerated and increase her ambulation distance which is primarily endurance training 
and does not require intensive therapy. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $72.45 deductible for laboratory services performed on 
February 7, 2022. 
 
You asked the Plan to waive the $72.45 deductible for laboratory services performed on February 7, 2022. You 
say that you should not be responsible to pay this amount because the services are part of your annual wellness 
visit. The Plan denied your request. The Plan says you have a $100 deductible for most Part B in-network and 
out-of-network services.  
 
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 a $72.45 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $72.45 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time laboratory services was received on February 7, 2022. Therefore, we decided that the Plan does not have 
to waive the $72.45 deductible for laboratory services performed on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine foot care. 
 
You asked the Plan to pre-approve routine foot care. You say that you feel these services should be covered. 
The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pre-
approve are routine foot care services. Based on this information, we decided that Medicare rules for coverage 
of routine foot care have not been met. Therefore, we decided that the Plan does not have to pre-approve 
routine foot care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve epidural steroid injection. You say that you cannot feel your hands and are 
losing balance. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because you do not meet the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injections are covered if 
certain criteria are met and if the prior injection provided improvement for at least 3 months. 
 
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 epidural steroid injection. Our reviewer 
says that you do not meet the Medicare criteria for the requested epidural. Our physician reviewer found repeat 
epidural can be considered when the first injection directly and significantly provided improvements in pain 
relief and/or function for at least 3 months. However, your most recent epidural steroid injection was 
performed on June 13, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213), and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve a partial upper denture and a partial lower denture. You say that the 
requested services are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not covered benefits. 
 
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 pre-approve a 
partial upper denture (D5213), and a partial lower denture (D5214).
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 enrollee has on-going and complex 
medical needs, and she is stable for transfer to LTACH. The treating physician states the enrollee requires close 
medical monitoring, daily physician management, and intensive skilled services. The Plan denied your request. 
The Plan says authorization denied because the LTACH is not medically necessary, and the enrollee can 
continue to stay at the acute hospital until she is stable for discharge to a lower level of 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 appears to be more stable and improving and should only require short-
term additional acute care services that can be safely completed at the current facility until appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already 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 long term acute care hospital (LTACH) 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at a lower level of 
care such as at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that while you may benefit from continued physical therapy and occupational therapy, your rehabilitation needs can be safely provided in an alternate setting such as in 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is the safest discharge plan. You also 
say it allows for the highest potential of recovery. You also say that this would prevent further deterioration and 
best use of medical management. The Plan denied your request. The Plan says the member is receiving 
appropriate in-patient acute care and does not require transfer to a long-term acute care hospital. 
 
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 patient appears to be more stable nearing baseline and should only require short-
term additional acute care services that can be safely completed at the current facility until appropriate for a 
lower level of care. Our physician reviewer also found that transfer to LTACH is not medically necessary as it 
would not be clinically advantageous. 
 
 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: 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 enrollee cannot stay in the current 
facility because they do not have bedside dialysis and member is requiring bedside dialysis based on his 
medical condition. The enrollee is denied because they are saying he needs to sit in a dialysis chair, but the 
enrollee cannot do that. The Plan denied your request. The Plan says authorization because the LTACH is not 
medically necessary, and the enrollee's medical needs are being met in the current acute setting. 
 
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 record indicates that the enrollee has had a prolonged hospital course and, 
although is improving, still require acute care services before transitioning to a lower level of care. The enrollee 
continues to receive acute care services, and these have not been denied. 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $17.76 copayment for an electrocardiogram (ECG) 
performed on January 26, 2022. 
 
You asked the Plan to waive the $17.76 copayment for an ECG performed on January 26, 2022. You say that 
you should not be responsible for this amount because the test was performed in your Primary Care Physician's 
office. The Plan denied your request. The Plan says you are responsible for a $17.76 copayment for in-network 
non-radiological diagnostic services. 
 
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 $35 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $17.76 copayment for an ECG performed on January 26, 2022. An ECG falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Since this is 
less than the Plans contracted copayment, you are only being liable for the lower amount. 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 $17.76 copayment for an electrocardiogram (ECG) performed on January 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xtampza extended-release. 
 
You asked the Plan to pre-approve Xtampza extended-release. You say that the enrollee has tried and failed 
short acting medications with no relief. You also say that you are prescribing Xtampza for the enrollee to trial 
for relief. The Plan denied your request. The Plan says this drug is intended for patient self-administration. The 
Plan also says that this drug is not covered for the enrollee's condition by Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xtampza extended-release.