Persius/hicric huggingface dataset:
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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the member's medical conditions are stable and there are no complex nursing or 
rehabilitation needs.  While the member may have a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. 
 
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. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an added tooth to an existing partial denture (D5650) 
provided by a participating provider on January 12, 2022. 
 
You asked the Plan to pay for an added tooth to an existing partial denture. You say that you are a piece of 
banana nut bread and one of your teeth fell out. The Plan denied your request. The Plan says this claim has 
been correctly processed and denied. 
 
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 an added 
tooth to an existing partial denture (D5650) provided by a participating provider on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that this device is medically reasonable and necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that while the patient has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
patients clinical management. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a duplex scan of extremity veins including 
responses to compression and other maneuvers. 
 
You asked the Plan to waive the deductible for a duplex scan of extremity veins including responses to 
compression and other maneuvers. You say that you are being billed for services which are unexpected since 
you were in an in-network facility with prior authorizations. The Plan denied your request. The Plan says you 
were 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 $750 
deductible for all items and services except those specifically excluded by the Plan contract.  
 You have been asked to pay $21.48 for a duplex scan of extremity veins including responses to compression 
and other maneuvers. A duplex scan of extremity veins including responses to compression and other 
maneuvers falls 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 a $750 deductible, 
which applies to outpatient diagnostic tests and therapeutic services and supplies. 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 that had not been met at the time a duplex scan of extremity veins including responses to 
compression and other maneuvers received on September 29, 2021. Therefore, we decided that the Plan does 
not have to waive the deductible for a duplex scan of extremity veins including responses to compression and 
other maneuvers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided on December 7, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that the last time your hearing aid benefit was used was 
in 2017. You also say that you understand the total was more than $1,000, but you do not understand why at 
least $1,000 was not paid. The Plan denied your request. The Plan says the service is a covered benefit, but you 
have exceeded the limits set in the subscribers agreement. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays up to 
$1,000 for hearing aids only every 3 years.  
 
We looked at the file and the Plan's rules. The record shows that you received hearing aid services on June 24, 
2019, and your maximum allowance for hearing aid services was reached. Based on this information, we 
decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the 
Plan does not have to pay for the hearing aids (V5298) provided on December 7, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high-intensity focused ultrasound (HIFU) services 
(55880). 
 
You asked the Plan to pre-approve HIFU services. You say that these services are medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage of HIFU treatment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that high-intensity focused ultrasound (HIFU) is 
considered medically necessary as a local treatment for recurrent prostate cancer when it is following radiation 
therapy (RT). 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that no radiation therapy has 
yet been completed. Based on this information, we decided that Medicare rules for coverage of HIFU services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve high-intensity focused 
ultrasound (HIFU) services (55880).
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 needed because the enrollee needs 
therapy to recover his independence and endurance. The Plan denied your request. The Plan says IRF care is 
not medically necessary because the enrollee can be managed at a lower level of care. 
 
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 does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
13, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you had an annual physical 
and feel you should not have to pay a lab copayment since they were done on the same day. 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 $10 
copayment for laboratory tests that are not FIT (fecal immunochemical tests) tests. The Plan contract also says 
that you pay a $0 copayment for an annual physical. The contract says if you receive services that address a 
medical condition during the same office visit, additional cost-share may apply. 
 
According to the EOC, laboratory services are not part of an annual physical, and a cost sharing amount 
applies. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a molecular pathology procedure provided on February 22, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a molecular pathology procedure. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services were not urgent or emergent. 
 
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 a molecular 
pathology procedure provided on February 22, 2022 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the five additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve the five additional home health skilled nursing visits. You say that the 
service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 five additional home health skilled 
nursing visits. Our reviewer says that the service is not medically necessary. Our physician reviewer found you 
have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations 
and the most recent documentation indicates there is no further need for skilled nursing services for wound 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the five additional home health skilled nursing visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the five additional home health skilled 
nursing visits.
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 LTACH is needed because the patient is 
on a lot of antibiotics for wound care and that is not offered in the acute hospital setting. The Plan denied your 
request. The Plan says records do not show unique continued treatment and care that can only be given in a 
hospital setting. The patient can be managed in another 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 patient is currently undergoing treatment at an acute care hospital (ACH) for 
septic arthritis.  The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services 
that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, there is 
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair 
(E2300). 
 
You asked the Plan to pre-approve the power seat elevation feature for a power wheelchair. You say that this 
feature is medically necessary. The Plan denied your request. The Plan says power seat elevation features are 
non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested feature is not covered under Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the power seat elevation feature for a power 
wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation feature for a power wheelchair (E2300).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 6, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER on October 4, 
2021. You say that X-rays were not taken so you had to return. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit 
provided on October 6, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 11, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you left the ER after waiting for 3.5 
hours. You say the receptionist informed you that you would not be charged. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit 
provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 8, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration for the denied claim. 
The Plan denied your request. The Plan says the rendering provider is an OON provider and there was no 
referral from an in-network provider. Also, there are in-network provider available to provide the service that 
was rendered. 
 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 provided on December 8, 2021, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on January 9, 2022 to January 
10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Laboratory services provided on January 9, 2022 
to January 10, 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 provided on December 1, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the treatment you provided to the enrollee was 
medically necessary and you would like the denial of the claim to be overturned. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 provided on December 1, 2021, by 
an OON provider.