Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health physical therapy visits. 
 
You asked the Plan to pre-approve 5 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 5 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care. As such, the requested, ongoing, home health physical therapy services 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 5 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on October 28, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you would like the authorization 
requirement waived and for the services to be paid. 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 the nursing facility care provided on October 28, 
2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
11, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the insurance company told 
you they would process payment for this bill. 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 $250 
copayment for ground ambulance services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$250 copayment for ambulance services. Ambulance services fall within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ambulance services provided on December 11, 
2021.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet blocks (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet blocks. You say that the requested services are a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services 
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 facet blocks. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee did not achieve the required level of pain relief with prior treatments. Further, to qualify 
for therapeutic facet injections there must be documentation as to why radiofrequency ablation is not an 
alternative. There is no such available documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet blocks (64493, 64494, 64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose 
monitor (CGM) sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 therapeutic CGM sensor. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 2 therapeutic 
CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 therapeutic continuous glucose monitor (CGM) sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for aflibercept injections provided from 
January 11, 2021, to December 17, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you have never been charged for 
your routine eye injections before. 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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $737.40, which is 20% coinsurance of the allowed amount for each injection 
received on January 1, 2021, June 28, 2021, August 27, 2021, October 22, 2021, and December 17, 2021 
($3,687.02 allowed amount x 20% coinsurance = $737.40). An injection falls within the Medicare Part B 
Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for aflibercept injections provided 
from January 11, 2021, to December 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services provided on 
October 29, 2021 to January 5, 2022. 
 
You asked the Plan to waive the copayment for cardiac rehabilitation services. You say that you were never 
told you had a copayment until after attending 20 classes of the cardiac rehab program. The Plan denied your 
request. The Plan says the coinsurance is correct. 
 
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 $50 
copayment for Medicare-covered cardiac rehabilitation services.  
 
  You have been asked to pay $1050 for cardiac rehabilitation services ($50/visit x 21 = $1050). Cardiac 
rehabilitation services fall within the Cardiac rehabilitation services benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for cardiac rehabilitation services provided on October 29, 2021 to 
January 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy. 
 
You asked the Plan to pre-approve Yervoy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Yervoy as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Yervoy.
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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with chest pain and shortness of breath with acute respiratory failure and non-ST 
elevated myocardial infarction (NSTEMI) requiring stent placement. She is currently unstable and should only 
require short-term additional acute care services that can safely be administered at the current facility until she 
is more stable. She does not require services at the LTACH that are not already available and covered at the 
current facility. The LTACH services are not reasonable or medically 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture (additional 15-minute intervals) and infrared 
therapy provided from August 19, 2021, to September 9, 2021. 
 
You asked the Plan to pay for acupuncture and infrared therapy. You say that you are appealing with notes to 
support medical necessity. The Plan denied your request. The Plan says the denial of payment for these services 
is correct, because the records submitted do not support 3 units of code 97814 and because infrared therapy is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that infrared therapy is non-covered. 
 
In this case, the CPT Code Manual definition of code 97814 is acupuncture, 1 or more needles; with electrical 
stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of 
needle(s) (list separately in addition to code for primary procedure). 
 
We find that CPT code 97814 is not supported in the medical record. Specifically, the record shows that each 
visit included a total of 45 minutes of personal one-on-one contact with the patient, which does not support the 
billing of 3 units of code 97814. Additionally, infrared therapy is not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of acupuncture and infrared therapy have not been 
met. Therefore, we decided that the Plan does not have to pay for acupuncture (additional 15-minute intervals) 
and infrared therapy provided from August 19, 2021, to September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Services provided on January 3, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Services. You say that you would like to request reconsideration for 
payment. 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. Also, 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 Outpatient Services provided on January 3, 2022 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the imaging services provided on 
December 30, 2021. 
 
You asked the Plan to waive the copayment for the imaging services. You say that you hit your MOOP so there 
should be no copayment applied. The Plan denied your request. The Plan says the enrollee did not hit there 
MOOP prior to the date of service therefore the proper copayment was applied. 
  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 $15 
copayment for each Medicare-covered standard X-ray service. Prior to the date of service, the total amount 
paid toward the MOOP was $4,785. With the copayment amount of $15 for the date of service the total MOOP 
for the year was $4,800 ($4,785 prior MOOP paid + $15 copayment). 
 
You have been asked to pay a $15 copayment for the imaging services. The imaging services falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the imaging services provided on December 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that it is dangerous to move to a different location. 
The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of 
SNF care is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic hand. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested prosthetic exceeds the 
enrollee's medical needs. There is no physical exam of the right upper extremity by the treating medical 
provider. The treating medical provider prescription states "right fingers prosthesis" without clear details of the 
need for ultralight and acrylic materials. Without specific details and support in the provider note, the services 
cannot be considered reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic hand.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261) 
provided September 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON hearing aids. You say that you believe this provider is now 
participating. The Plan denied your request. The Plan says this service is not covered because you did not use 
the Plans hearing aid vendor. 
 
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 for 
hearing aids only from the Plans hearing aid vendor. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were not ordered through the Plans 
hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the OON 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid, 
digital, binaural, behind the ear (V5261) provided September 20, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99454), 
the remote physiologic monitoring treatment management services, first 20 minutes (99457), the remote 
physiologic monitoring treatment management services, each additional 20 minutes (99458), the complex 
chronic care management services (99487), and the complex chronic care management services, each 
additional 30 minutes (99489) rendered by the out-of-network (OON) provider on January 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the remote monitoring of physiologic parameter(s) (99454), the remote 
physiologic monitoring treatment management services, first 20 minutes (99457), the remote physiologic 
monitoring treatment management services, each additional 20 minutes (99458), the complex chronic care 
management services (99487), and the complex chronic care management services, each additional 30 minutes 
(99489) rendered by the out-of-network (OON) provider on January 31, 2022.