Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on June 8, 2021. 
 
You asked the Plan to pay for these services. You say that the services are not billed correctly. The Plan denied 
your request. The Plan says that [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 Plan references Local Coverage Article (LCA) A56853 in their 
determination; however, these rules are not binding for the state of Massachusetts where the testing was 
performed. The Plan has not provided any Medicare rules or documentation to support the services are not 
payable as billed. Therefore, we decided that the Plan has to pay for the laboratory services rendered on June 8, 
2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) 
provided on March 25, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you could not have all 3 MRIs on the 
same day due to your condition. You say you would like this copayment waived. 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 $225 
copayment for each advanced imaging service, including MRIs.  
 
You have been asked to pay a $225 copayment for the MRI. An MRI 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 magnetic resonance imaging (MRI) provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture and routine chiropractic services rendered 
from April 12, 2022, to May 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you have exceeded the benefit limit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation. However, for services provided on or after January 21, 2020, Medicare offers limited coverage 
for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no 
more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture and 
chiropractic benefit. benefit. As such, the Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that you used all 18 of the covered 
additional routine chiropractic and acupuncture visits from January 5, 2022 to April 5, 2022. Further visits are 
not covered by the Plans supplemental benefit or your medical benefit. Therefore, we decided that the Plan 
does not have to pay for the acupuncture and routine chiropractic services rendered from April 12, 2022, to 
May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the 20% coinsurance charged for a life vest provided on 
September 12, 2021. 
 
You asked the Plan to waive this coinsurance. You say that you do not believe this coinsurance is correct. The 
Plan denied your request. The Plan says this coinsurance was charged based on the medical records and the 
Plan contract agreement. 
 
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 durable medical equipment. You have been asked to pay 20% coinsurance for this coinsurance. 
this coinsurance falls within the durable medical equipment 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 20% coinsurance charged for a life vest provided on September 12, 2021.
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 medical records support the need for IRF care. 
The Plan denied your request. The Plan says that the guidelines for coverage have not been met. The Plan says 
that the member could receive care in another setting. 
 
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 complexity of the members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is 
no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status.  The member can receive further services 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: 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 member will benefit from IRF care. The Plan 
denied your request. The Plan says the member does not meet IRF criteria, but a lower level of care could be 
considered. 
 
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 complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is 
no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status. The member can receive further services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits you had on December 13, 
2021, and January 17, 2022. 
 
You asked the Plan to waive the copayments for the office visits. You say that this provider is your PCP, so 
there should be no copayment. The Plan denied your request. The Plan says you were charged these 
copayments 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 $40 
copayment for visits with a specialist for services in 2021 and a $35 copayment for visits with a specialist in 
2022.  
 
 You have been asked to pay a $40 copayment for the office visit in 2021 and a $35 copayment for the office 
visit in 2022. Your Evidence of Coverage states that unless you see your PCP, the specialist copayment applies.  
We have confirmed that the provider that you saw on these two dates is not the provider listed as your PCP.  If 
you wish to change your selected PCP, you will need to contact the plan directly.  Because the provider you 
saw is not your listed PCP, the specialist copayment applies. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for the office visits you had on December 13, 2021, and January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on May 10, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you feel that you should not owe anything 
for the DME services due to being pressured into signing the paperwork for it. The Plan denied your request. 
The Plan says the coinsurance applied 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 20% 
coinsurance of the plan-allowed amount for Medicare-covered durable medical equipment.  
 
You have been asked to pay $647.77, which is 20% of the total allowed amount for the DME ($3,238.86 
allowed x 20% = $647.77). DME falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for DME provided on May 10, 
2022.  Your complaint about feeling pressured into signing the paperwork for the DME is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tacrolimus ointment. 
 
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 self-administered drugs are not covered. 
 
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 Tacrolimus ointment.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Go Go brand power scooter. 
 
You asked the Plan to pre-approve these services. You say that you need an upgraded power scooter to go 
faster than the one you have for traveling on the street. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Go Go brand power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for admission. 
 
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 require treatment by multiple therapies in an intensive 
rehabilitation therapy program. The enrollee can receive further services 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 IRF admission and 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 this is medically necessary. The Plan denied your 
request. The Plan says 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 in this case, the complexity of your nursing, medical and rehabilitation needs do 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that you 
would meet criteria for admission to IRF. There is no indication that you would require skilled rehabilitation in 
an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain your functional status. You can receive further services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home COVID-19 tests you purchased on January 20, 2022. 
 
You asked the Plan to pay for the home COVID-19 tests. You say that you believed these would be covered 
starting on January 15, 2022. The Plan denied your request. The Plan says for Medicare Advantage members, 
coverage of COVID-19 home tests was not available until April 4, 2022.  You purchased these tests prior to 
that date. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare Advantage members, coverage of 
at-home COVID-19 tests is available after April 4, 2022.  You purchased these tests prior to that date.  The date 
of January 15, 2022, is the date that MA plans could, if they wished, offer a supplemental benefit covering 
COVID-19 tests.  Your MA plan had no such supplemental benefit, so the April 4, 2022, date applies.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home COVID-19 tests have not been met. Therefore, we decided that the Plan does not have to 
pay for home COVID-19 tests you purchased on January 20, 2022.
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 enrollee is not receiving proper care at the skilled 
nursing facility. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF 
services do not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs do not require an acute rehab 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, at an intensive rehabilitation therapy program. The enrollee does continue to need skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does not 
support that the criteria for admission to an acute inpatient rehabilitation facility are met. There is no indication 
that the enrollee would require a minimum of 15 hours per week of skilled rehabilitation services in an IRF 
under the supervision of a physician with at least three physician visits weekly to regain or maintain functional 
status. The enrollee can receive further services 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: 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 this is medically necessary. The Plan denied your 
request. The Plan says this 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 in this case, the complexity of your nursing, medical and rehabilitation needs do 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the 
supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. You can 
receive further services 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.