Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you were denied for medical equipment. 
The Plan denied your request. The Plan says there is no documentation that all the criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition. 
 
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 SSBCI benefits. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have chronic kidney disease, diabetes mellitus type 2, hypertension, heart failure, 
and hyperlipidemia. The medical record did not sufficiently support medical necessity because you do not meet 
all three of the criteria. Although you have many chronic, stable conditions being managed appropriately by the 
treating physician, you do not have an active diagnosis for one or more qualifying comorbid and medically 
complex conditions. Your conditions are not life-threatening or significantly limiting your overall health or 
function. You do not require intensive care management or at high risk for hospitalization.   
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 SSBCI benefits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that prostate artery embolization is 
medically necessary. The Plan denied your request. The Plan says the requested prostate artery embolization is 
experimental. 
 
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 prostate artery embolization. Our 
reviewer says that the requested prostate artery embolization is not considered medically reasonable and 
necessary. Our physician reviewer found that prostatic arterial embolization (PAE) is considered an 
experimental technique to treat symptomatic benign prostatic hypertrophy (BPH). Very limited studies have 
demonstrated possible short-term safety and efficacy. The most recent American Urological Association 
(AUA) guidelines do not recommend this procedure outside of a clinical trial setting due to the heterogeneity in 
the available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular 
access, technical feasibility, higher clinical failure rate compared with more traditional methods  (e.g., transurethral resection of the prostate [TURP]). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Toric lens (V2787), provided on October 6, 2022, 
through October 19, 2022. 
 
You asked the Plan to pay for the Toric lens. You say that the service should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the Toric lens 
(V2787), provided on October 6, 2022, through October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skin biopsy provided on October 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a skin biopsy. You say that this was medically necessary; you do not understand why you are out-of-network with this Plan. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld.
 
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 skin biopsy provided on October 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on November 8, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our 
physician reviewer found the transportation via ambulance from the hospital to the enrollee's residence was not 
medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport.  Transportation could have been provided by other 
means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on November 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you do qualify for this benefit, and you have 
medical records stating such. The Plan denied your request. The Plan says that based on the information 
submitted there is no documentation that you meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records show that an attestation from your provider was sent to the Plan, but 
this was not provided to us. The Plan also says multiple attempts were obtained to obtain medical records, but 
the records provided do not show when or how many attempts were made by the Plan to obtain this 
information. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-
approve special supplemental benefits for the chronically ill (SSBCI).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that you are unable to check your 
glucose multiple times a day. The Plan denied your request. The Plan says there is no documentation that you 
use multiple insulin treatments daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back surgery (22510). 
 
You asked the Plan to pre-approve a back surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation (PVA) for 
Osteoporotic Vertebral Compression Fracture (VCF) is covered when the criteria in the Medicare Rules section 
is met. 
 
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 a back surgery. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the record provided is insufficient to 
establish that 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 a back surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a back surgery (22510).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says all services that would be provided in the Long-Term 
Acute Care Hospital (LTACH) are being provided in the current acute care setting which is already approved. 
Therefore, the requested Long-Term Acute Care Hospital (LTACH) services are not medically necessary, 
reasonable, or appropriate for the diagnosis and condition of the enrollee currently. The enrollee can remain in 
the current acute care location until such time no further acute level care is needed. 
 
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 transfer to the LTACH is not medically necessary as the patient is not yet stable for 
transfer and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended.  
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zoll Life Vest. 
 
You asked the Plan to pre-approve a Zoll Life Vest. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there is no medical indication for the continuation of the Life Vest after the 
hospital admission. 
 
The Plan follows Medicare rules. Medicare rules say that a wearable defibrillator (K0606) is covered for 
beneficiaries if they meet one of the criteria listed 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 a Zoll Life Vest. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found the member already has a defibrillator implanted making a wearable defibrillator unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Zoll Life Vest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Zoll Life Vest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth service provided on October 10, 2022. 
 
You asked the Plan to pay for a telehealth service. You say that you were unaware that the patient had changed 
their plan, and that you were not out-of-network. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a telehealth service 
provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care visit provided on November 
08, 2022. 
 
You asked the Plan to waive the copayment for a primary care visit. You say that you think that this visit 
should be covered. 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 $10 
copayment for each covered visit or consultation in an outpatient location with your primary care physician or 
other primary care provider. 
 
You have been asked to pay a $10 copayment for a primary care visit. This item/service falls within the each 
covered visit or consultation in an outpatient location with your primary care physician or other primary care 
provider benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a primary care visit 
provided on November 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.

You asked the Plan to pre-approve an inpatient level of care for the approved surgery. You say that the requested inpatient level of care for the approved surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient level of care for the approved surgery is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an inpatient level of care for the approved surgery. Our reviewer says that the requested inpatient level of care for the approved surgery is not medically necessary. Our physician reviewer found the record indicates that the enrollee is scheduled for left total shoulder arthroplasty and left distal clavicle resection. The record provided does not indicate that the medical condition, safety, or health of the enrollee would be significantly and directly threatened if care was provided in a less intensive setting. The initial day may be spent in observation until it is clearly expected that an inpatient stay would be required, at which time the physician may order inpatient admission. The elements of the coverage criteria are not satisfied. The requested service is not recommended.

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 inpatient level of care for the approved surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient level of care for the approved surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee does not require an intensive rehabilitation physician or nursing oversight in an IRF. The 
enrollee's functional level does not require treatment by multiple therapies including physical therapy or 
occupational therapy in an intensive rehabilitation program in an IRF. While the patient may have a need for 
additional therapy, the documentation does not support that the enrollee requires this therapy on an IRF level. 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you really need these supplies. The Plan 
denied your request. The Plan says the requested supplies are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.