Persius/hicric huggingface dataset:
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 LTACH services. You say that the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH care 
have not been met. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving and requires only short-term additional 
acute care services that can safely be administered at the current facility until the enrollee returns to baseline. 
The enrollee does not require services at the LTACH that are not already available at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on September 15, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says 
members are required to contact the Plan's hearing vendor to receive the routine hearing exam and 
supplemental hearing aid benefits. 
 
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 when you contact the Plans hearing vendor. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing vendor. 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 reimburse you for hearing aids 
provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix test strips. 
 You asked the Plan to pre-approve the True Metrix test strips. You say that the True Metrix test strips are 
medically necessary. The Plan denied your request. The Plan says this brand of test strips are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The records provided do not show any reason the preferred brand of 
test strips do not meet the enrollee's needs. Based on this information, we decided that Medicare rules for 
coverage of the True Metrix test strips have not been met. Therefore, we decided that the Plan does not have to 
pre-approve True Metrix test strips.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
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 care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found physical therapy has increased the enrollee's 
recommended frequency of PT to 5-7 x/week to facilitate progress with functional mobility. The 
documentation in the case file supports that it is medically reasonable and necessary to provide skilled therapy 
services on a daily basis on an inpatient basis, in a skilled nursing facility. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 the requested device. The Plan denied your request. The Plan says the 
enrollee does not need to change his insulin dose frequently. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
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 you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not 
meet Medicare criteria for coverage of the requested IRF 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 complexity of the member's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's 
medical status does not require intensive physician and nursing oversight in an IRF. While the member may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the member requires this therapy on an intensive IRF level or can tolerate an intensive IRF 
level 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. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the requested 
drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not medically 
necessary for the treatment on the member's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Prolia. Our reviewer says that there is 
no evidence of osteopororis. The review has determined that the documentation does not support that the Prolia 
is medically reasonable and necessary for the member. Our physician reviewer found the documentation does 
not support that the Prolia is safe and effective for the member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pogo test strip kit. 
 
You asked the Plan to pre-approve these services. You say that you feel it is needed for your type II diabetes. 
The Plan denied your request. The Plan says the services are available from the preferred providers. 
 The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies. 
 
We looked at the file and Medicare rules. The requested diabetic testing strips are from a non-preferred 
provider. The services are available from the Plan's preferred providers. Therefore, we decided that the Plan 
does not have to pre-approve a Pogo test strip kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that you would like reconsideration because the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the member does not have 
evidence of severe disc disease or severe central or foraminal stenosis. 
 
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 the ESI. Our reviewer says that the 
enrollee did not satisfy the criteria for coverage for the epidural steroid injection services. Our physician 
reviewer found in this case, there is radiculopathy, but no radiological evidence of disc herniation, osteophyte 
or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal stenosis. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on September 25, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiology services provided to the enrollee on September 25, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so the claim 
should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no in-network provider referral. Also, the services provided 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 an office visit provided on July 29, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standard wheelchair (K0001) and elevating leg rests 
(K0195) provided on October 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a standard wheelchair and elevating leg rests. You say that a representative from 
the Plan called you and stated that an authorization was not required. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan, and they have also determined that these services are 
not urgent/emergent, nor were they approved in advance. 
 
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 standard wheelchair (K0001) and elevating leg 
rests (K0195) provided on October 11, 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 a domiciliary or rest home visit (99336) provided on October 
18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the nursing facility's 
responsibility to get authorizations for their patients. You also say that you did not know that the facility failed 
to get pre-authorization for this patient, so you treated this patient anyway. The Plan denied your request. The 
Plan says an authorization was not obtained prior to the services being rendered and the provider is not 
participating with the member's Plan, and it was determined that the services were not urgent or emergent in 
nature. 
 
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 domiciliary or rest home visit (99336) provided 
on October 18, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 6, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that the exam was medically necessary. The Plan 
denied your request. The Plan says your medical Plan does not cover routine eye exams (eye refractions) for 
eyeglasses/contacts. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network 
(OON) provider on March 18, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on March 18, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 31, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that this service was provided post-surgery and 
your primary care physician should have sent a referral. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider with no in-network provider referral. Also, the service 
provided 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 imaging services provided on August 31, 2020, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
7, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
fully covered as they would cause a financial hardship. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 out-of-network laboratory services for Outpatient diagnostic tests and therapeutic services 
and supplies.  
 You have been asked to pay a $29.88 copayment for out-of-network laboratory services, which is less than the 
$40 copayment stated in the Plans contract. 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 September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography (93306) provided on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that the services should be 
covered in full as you weren't aware of the copayment beforehand. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services provided. 
 
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 $150 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay a $150 copayment for an echocardiography. Echocardiographys 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 an echocardiography (93306) provided on October 15, 2021.