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

 
We decided that the Plan does not have to pay for home health services provided on August 29, 2023. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on August 29, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the psychotherapy provided on June 12, 
2023. 
 
You asked the Plan to pay for the office visit and the psychotherapy. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and the 
psychotherapy provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chest x-rays provided on September 15, 2023. 
 
You asked the Plan to pay for chest x-rays. You say that you made every effort possible to stay in-network. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chest x-rays provided on 
September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 
28, 2023. 
 
You asked the Plan to pay for the dental service. You say that you have a $2,000 deductible The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on dates of service April 4, 2023, and 
September 18, 2023. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140) provided on September 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (code J3490) provided on June 9, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this was a medically necessary part of the enrollee's 
treatment. The Plan denied your request. The Plan says payment for this local anesthetic is included in the 
global package for surgical code 20610. 
 
The Plan must follow Medicare rules. Medicare rules say that intra-operative services that are normally a usual 
and necessary part of a surgical procedure are included in the global surgical package and not separately 
payable.  
 
We looked at the file and Medicare rules. This local anesthetic bupivacaine is a usual and necessary part of 
surgery; therefore, it is not separately paid from the global surgical package. Based on this information, we 
decided that Medicare rules for coverage of bupivacaine have not been met. Therefore, we decided that the 
Plan does not have to pay for bupivacaine (code J3490) provided on June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on October 9, 2023. 
 
You asked the Plan to pay for the dental service. You say that this was not a regular visit but one that required a 
cavity filling. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on dates of service January 4, 2023, and 
April 6, 2023. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) 
provided on October 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. You say that the drug is medically necessary. 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 Repatha.   
Benefits for Repatha 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: 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 these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and is currently unstable for transfer 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 appears to be improving with current treatment but is still somewhat 
unstable and requires additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer.  The enrollee does not require services at the LTACH that are not already available at the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have not received any therapy because the 
therapists quit and would like these days reinstated. The Plan denied your request. The Plan says your records 
do not show you require skilled rehabilitation services daily that can be provided only on an inpatient basis in a 
SNF and have no ongoing skilled nursing or medical needs that require daily management. The Plan says 
services you require can safely be received at a different setting, home with home health, in residential care, or 
home with close follow-up with your physician. 
 
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 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 skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5011, V5241) purchased on July 27, 
2023. 
 
You asked the Plan to pay for the hearing aids. You say that you want the Plan to pay for the hearing aids. The 
Plan denied your request. The Plan says hearing aids purchased out-of-network are not covered. 
 
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 utilize an in-network provider.  
 
We looked at the file, and the Plan's rules. 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 pay for 
the hearing aids (V5011, V5241) purchased on July 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has not exhausted the 100-day benefit. 
The Plan denied your request. The Plan says the enrollee has exhausted the 100-day benefit for SNF care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 27, 2023, to 
November 16, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 LTACH level of care is necessary to 
address the enrollee's complex medical needs. The Plan denied your request. The Plan says the criteria for a 
LTACH admission has 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 patient has made only small improvements within their medical condition. Short-
term additional acute care services can be safely provided at the current facility until they are more stable and 
appropriate for transfer to a lower level of care. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility 
is 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 LTACH 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 enrollee currently meets LTACH 
admission criteria under CMS guidelines. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and is currently unstable for transfer 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 seems to be making progress and is now on 2 L of supplemental oxygen, 
no longer requires dialysis, an ileus seems to have resolved and does meet LTACH admission criteria. 
 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: 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 disagree with this denial and requesting a 
reconsideration for admission to an inpatient rehabilitation facility. The Plan denied your request. The Plan 
says the records do not identify medical complexity that meets the criteria for you.  
 
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. The medical records 
support 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. It 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on October 5, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you are requesting to reconsider 
the claim for payment and are seeking for review. The Plan denied your request. The Plan says this service is 
not supported by the documentation submitted and is not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that the delivery services package identification 
number, supplier invoice number, or alternative method that links the suppliers delivery documents with the 
delivery services records must be included. 
 
We looked at the file and Medicare rules. The invoice did not include the carriers tracking number. Based on 
this information, we decided that Medicare rules for coverage of the supply allowance for a CGM have not 
been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on October 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid circulating cold pad with pump (E0218).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on Aug 8, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not enrolled in Medicare as a durable medical 
equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on Aug 8, 2023.
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 the enrollee is not a candidate for a lower 
level of care. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that 
cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a 
therapeutic advantage. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and appropriate for transfer to a lower level of care soon. The enrollee does not require services at the LTACH that 
are not already available at the current facility. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH is not medically 
necessary as it would not be clinically advantageous at this time. Completion of treatment at the current facility 
is 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 LTACH services.