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 the LTACH services. You say that the LTACH level of care can manage the 
enrollee's pulmonary, cardiac, renal, nutritional and therapy needs. You say the enrollee will be seen daily by 
internal medicine. The Plan denied your request. The Plan says criteria for admission to the LTACH 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 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 has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The enrollee 
does not require services that they are not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit on provided on July 19, 
2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you should not be responsible for 
this amount. 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 says that you have a $490 deductible, which applies to an out-of-network office visit. 
The Plan contract also says that you must pay 50% coinsurance for an office visit after the deductible has been 
met. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $490 deductible, which applies an to out-of-network office visit. This cost sharing is a contractual 
obligation that had not been met at the time the out-of-network office visit was received on July 19, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on July 
19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of SPRINT peripheral nerve stimulator 
(PNS). 
 
You asked the Plan to pre-approve SPRINT PNS. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says percutaneous peripheral nerve stimulation (PNS) is unproven and not 
medically necessary due to insufficient evidence of efficacy. 
 
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 SPRINT PNS. Our reviewer says that 
the requested SPRINT PNS is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental/ investigational procedure.  Therefore, the reviewer found 
that the requested SPRINT PNS is not medically reasonable and 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 SPRINT PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of SPRINT peripheral nerve stimulator (PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the records show that the ventilator is going to be used only in a bi-level 
pressure mode as a respiratory assist device (RAD). 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, severe 
obesity with a body mass index (BMI) of 35, and heart failure with reduced ejection fraction. The enrollee was 
hospitalized twice in December for exacerbations of COPD and congestive heart failure. Arterial blood gases 
were consistent with acute on chronic carbon dioxide (CO2) retention. There are no pulmonary function tests to 
assess the severity of the COPD. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. This enrollee may benefit from BiPAP with volume assurance during sleep as an outpatient. The 
records do not document failure of BiPAP as an outpatient. Medicare does not cover a home ventilator when 
used at settings that can be provided with BiPAP. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy services provided on June 
02, 2022, to June 16, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy services. You say that you were not told that 
these would be the charges, and your Plan booklet did not have the accurate information. You feel you do not 
owe these charges. 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 20% 
coinsurance for Medicare Part B prescription drugs and related services. 
 
You have been asked to pay 20% coinsurance for chemotherapy services. This item/service falls within the 
Medicare Part B prescription drugs and related 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. The total you owe is $824.17 ($65.31+ $12.70 + $746.16). 
Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy services provided 
on June 02, 2022, to June 16, 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 if you are not fully recovered, you won't have the 
balance and strength you need to move on your own. The Plan denied your request. The Plan says the services 
you need can be provided safely in other settings, for example, a skilled nursing facility (SNF), at home with 
home health services or at home with outpatient therapy.  
 
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 your nursing medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have had no 
significant changes in your baseline conditions other than the hip fracture and no post-operative complications. 
You do not require the oversight of a rehabilitation physician. Your medical and rehabilitation needs do not 
require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. The records show you did not tolerate therapy well. You are dependent to requiring 
maximum assistance with bed mobility and transfers. You require minimal assistance with sitting at the edge of 
the bed. You have had a decline from your baseline level of function and may benefit from occupational and 
physical therapies as well as supervision and assistance, but you do not require the intensity of therapies 
provided on acute inpatient rehabilitation and it is unclear that you would benefit from or tolerate this intensity 
of therapy. Therefore, the acute inpatient rehabilitation admission is not 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 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that enrollee's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an LTACH. 
 
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 does not have complex wound care needs and does not meet LTACH 
criteria at this time. There is no therapeutic benefit to transfer to LTACH. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 9, 2023, to July 5, 
2023, billed with procedure code 92133. 
 
You asked the Plan to pay for the practitioner services provided. You say that the services were medically 
necessary and should be paid for. The Plan denied your request. The Plan says the services were not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have been met. Specifically, no medical records have been provided for review. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on May 9, 2023, to July 5, 2023, billed with procedure 
code 92133.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you need SNF services as you have a fracture of 
your tailbone and can't stand or walk. The Plan denied your request. The Plan says you do not meet the 
requirements for an SNF admission and services. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmology services described by codes J9035, 
67028, and 92134 performed on date of service June 29, 2023. 
 
You asked the Plan to pay for the ophthalmology services. You say that the ophthalmology services should be 
paid as billed because they are supported in the documentation, and the claim was filed as soon as possible 
after hearing back from the hospice provider. The Plan denied your request. The Plan says the ophthalmology 
services are denied because the claim was not billed with the required -GW modifier. 
 The Plan must follow Medicare rules. Medicare rules say that any covered Medicare services not related to the 
treatment of the terminal condition for which hospice was elected, that were performed during the hospice 
election period, may be billed by the rendering provider on a professional claim by appending modifier -GW to 
indicate the services are unrelated to the terminal condition.  
 
We looked at the file and Medicare rules. In this case, we confirmed that the enrollee was enrolled in hospice 
on the date of service in question. The case file contains documentation from the hospice provider indicating 
that the ophthalmology services were determined to be unrelated to the hospice admission diagnosis. We 
confirmed the ophthalmology services were billed on a professional claim. We also confirmed that no -GW 
modifier was appended to the codes on the claim. Per Medicare rules, services billed on professional claim that 
are not related to the treatment of the terminal condition for which hospice care was elected should be billed 
with -GW appended. Based on this information, we decided that Medicare rules for coverage of the 
ophthalmology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ophthalmology services described by codes J9035, 67028, and 92134 performed on date of service June 29, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro injection. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has been on this medication before 
and did well. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 Mounjaro injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior chamber intraocular lens provided on July 3, 
2023. 
 
You asked the Plan to pay for the anterior chamber intraocular lens. You say that you are requesting to be 
reimbursed for the vision services. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. The record shows the anterior intraocular lens is intended to treat astigmatism. 
Therefore, we decided that the Plan does not have to pay for the anterior chamber intraocular lens provided on 
July 3, 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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation does not 
support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on May 
11, 2023, to August 10, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you were billed twice for 
the laboratory service. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for in-network outpatient diagnostic tests and therapeutic services, including lab services. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the in-
network outpatient diagnostic tests and therapeutic services, including lab 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. The total amount you owe 
is $10, which is a $5 copayment for each laboratory service. Therefore, we decided that the Plan does not have 
to waive the copayment for the laboratory services provided on May 11, 2023, to August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 02, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you are requesting a waiver of the 
cost share fee. 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 $35 
copayment for in-network physician/practitioner services, including services provided by a Level 1 specialist. 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the in-network 
physician/practitioner services, including services provided by a Level 1 specialist 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 office visit provided on August 02, 2023.