Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided on February 23, 
2023, by an OON provider.  
 
You asked the Plan to pay for the ophthalmological services. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says the service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 ophthalmological services provided on 
February 23, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the facet joint blocking procedures and the 
facet joint denervation procedure provided on July 12, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayments for the surgery services. You say that you thought that the 
Department of Labor would cover the cost share. 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 $250 
copayment for Medicare-covered surgical services performed in an ambulatory surgical center.  
 
 You have been asked to pay a $250 copayment for each surgery service provided on July 12, 2023, July 25, 
2023, and August 30, 2023. These items/services fall within the outpatient surgery, including services provided 
at ambulatory surgical centers 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 copayments for the facet 
joint blocking procedures and the facet joint denervation procedure provided on July 12, 2022, to August 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lab testing to be provided by an out-of-network 
provider. 
 You asked the Plan to pre-approve the out-of-network services. You say that the drive will require multiple 
stops. The Plan denied your request. The Plan says there are in-network providers within a reasonable distance. 
 
Medicare rules say that plans must make care accessible to enrollees. The Plan says that enrollees must use 
contract providers.  
 
The requested provider is a non-contract provider. We were able to confirm that the Plan has contract providers 
located within reasonable distance and travel time from your home who can provide the lab services. Under 
Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan 
does not have to pre-approve lab testing to be provided by an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 You asked the Plan to pre-approve Stelara. The Plan denied your request. The Plan says the enrollee has not 
tried one of the preferred drugs.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Stelara. Our physician reviewer found 
that the enrollee has a diagnosis of Crohn's disease. The Plan requires a trial of Humira or Skyrizi before they 
will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is 
no documentation provided indicating that the Plans required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Stelara.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount the office visit provided on February 24, 
2023. 
 
You asked the Plan to pay an additional amount the office visit. You say that your liability for this service is 
the exact same charge as the total charged amount. You also say that you feel this claim was processed 
incorrectly. 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. Your 
contract with the Plan clearly says that you must pay a 10% coinsurance for Doctor and other health care 
provider services. Your contract with the Plan also says that there is a $800 annual deductible which applies to 
covered medical services.  
 You have been asked to pay a 10% coinsurance for the office visit. This service falls within the Doctor and 
other health care provider services benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $800 annual deductible which applies to covered medical services, and that there 
is a 10% coinsurance for Doctor and other health care provider services. These cost shares are a contractual 
obligation that had not been met at the time the office visit was received on February 24, 2023. Therefore, we 
decided that the Plan does not have to pay an additional amount the office visit provided on February 24, 2023.
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 services are medically necessary to prevent a 
decline in the enrollee's health. The Plan denied your request. The Plan says the enrollee does not meet the 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 the crowns - porcelain fused to high noble metal tooth #'s 22 
and 24 (D2750) provided on February 16, 2023. 
 
You asked the Plan to pay for the crowns. You say that these teeth have huge fillings as they have been 
restored many times over the years. You also say that upon clinical examination you found buccal gingival 
decay on both teeth and there was no other option but to place crowns in order to save them. The Plan denied 
your request. The Plan says the records show a crown to root ratio greater than 1:1.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
crowns are not medically necessary. Our physician reviewer found teeth 22 and 24 have large fillings on them. 
More than 50% of tooth structure is missing. Tooth 24 has severe decay around the existing filling, and tooth 
22 has decay around the existing large filling. The decay on tooth 24 is extensive. Both these teeth are severely 
compromised and with the information only from the x-ray, these teeth have a poor prognosis in which crowns 
are not necessary. There was not a periodontal chart, or photos included in the review that could provide 
support for the necessity of the crowns. The x-ray submitted only shows one view of the teeth. More 
information is required to make the determination that D2750 for teeth 22 and 24 were medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pay for the crowns - porcelain fused to high noble metal tooth #'s 22 and 24 (D2750) provided on 
February 16, 2023.
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 need this service as soon as possible. The Plan 
denied your request. The Plan says an 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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for pelvic and sacral fractures after a fall. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
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 this patient 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnogram (95811) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a polysomnogram. You say that it is in your medical opinion, an urgent 
matter that the patient has an in-lab sleep study done as soon as possible. The Plan denied your request. The 
Plan says this request cannot be approved, as participating providers are available in-network to provide this 
service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a polysomnogram (95811) to be provided by an out-of-network (OON) provider.
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 recently became a double amputee and 
needs the same level of care to get back to their life prior to their surgery. You say that the enrollee needs 
physical and occupational therapy everyday . The Plan denied your request. The Plan says an 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 pay for the office visit provided on February 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this visit was medically necessary as part of 
the overall treatment planning for the enrollee. The Plan denied your request. The Plan says prior authorization 
was not obtained. 
 
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 did not pre-approve the service 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 office visit provided on February 13, 2023, by an out-of-network (OON) 
provider.
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 your physician states that you can receive medical 
management of your current needs and can be seen daily by a physician at rehabilitation to reduce your risk of 
returning back to the hospital. You also say that your are eager to participate and complete the required 3 hours 
of therapy and unfortunately, you will not get that in a nursing home setting. The Plan denied your request. The 
Plan says based on Medicare guidelines, the IRF services you are requesting 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 you were admitted for infection at site of recent hip surgery. Medical problems are 
stable. There are no complex nursing or rehabilitation needs.  You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical 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 you 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: 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 only place the enrollee can go is to a 
LTACH level of care due to their medical needs. The Plan denied your request. The Plan says the enrollee's 
medical needs are being met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by Health Plan. Documentation does not support that LTACH services are medically appropriate 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 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.