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

 
We decided that the Plan does not have to pay for the annual wellness visit (G0439), provided on November 
30, 2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that the service should be covered. The Plan 
denied your request. The Plan says you have exhausted the benefit for this service. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439), provided on 
November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and the enrollee's needs can be met in another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine venipuncture (36415) and outpatient clinic visit 
(G0463) provided on January 25, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for routine venipuncture and outpatient clinic visit. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and there was 
no 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 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 routine venipuncture (36415) and outpatient clinic 
visit (G0463) provided on January 25, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14-day sensor. You say that you do not agree with the 
denial of the Freestyle Libre 14-day sensor. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 14-day sensor. Our 
reviewer says that the enrollee does not meet Medicare criteria. Our physician reviewer found the criteria for 
CGM coverage require either low blood sugars or insulin use. The enrollee, in this case, does not use insulin 
and is not having low blood sugars. We are also not told why fingerstick meter would not suffice for this 
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 a Freestyle Libre 14-day sensor. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre 14-day sensor.
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 would like to receive the services to help 
them get back to their prior level of function to return home independently. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery for removal of skin/tissue from the legs/thighs. 
 
You asked the Plan to pre-approve tissue removal surgery. You say that your skin is not getting better. The 
Plan denied your request. The Plan says this surgery is cosmetic in nature and is not covered. 
 
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 tissue removal surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have weight loss following bariatric surgery. The record does not provide 
documentation of functional limitation or chronic intertrigo which has not responded to conservative medical 
management, or the duration of stability of weight loss. There is insufficient documentation to support the 
safety and efficacy of this request.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tissue removal surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgery for removal of skin/tissue from the legs/thighs.
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 the enrollee is unable to walk without assistance or 
take of their personal hygiene. You also say it is not possible for the enrollee to return to their home as there is 
no one that provide care while their family is at work.  The Plan denied your request. The Plan says 
continuation of SNF services is not medically necessary.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor 
(33285).  
 
You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor. You say that this 
procedure is important to make a diagnosis of arrhythmia prior to committing to anticoagulant therapy. The 
Plan denied your request. The Plan says documentation shows no recent episode of syncope. 
 
The Plan follows Medicare rules. Medicare rules say that this service is covered when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
MLR. 
 
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 insertion of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
that there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any 
other apparent indication for an ILR. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ILR in this enrollees clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a subcutaneous cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm 
monitor (33285).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to retract payment and hold you harmless for the single vision lens (V2100) 
provided on December 14, 2022. 
 
You asked the Plan to retract payment and hold you harmless for the single vision lens. You say that you 
ordered and paid for glasses that you never received because the provider closed. You also say that you were 
never notified by the company, nor did you receive a refund. The Plan denied your request. The Plan says that 
the claim did not deny, but was processed correctly per the Plan's vision benefits. The Plan also says the claim 
was processed and allowed the $100 allowance to you for non-Medicare-covered prescription eyewear. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the single vision lens. Specifically, we have 
decided that the Plan must retract payment because there was no proof submitted showing that the provider 
really did furnish the eyewear. It is the burden of the Plan to substantiate their denial with evidence. In this 
case, the denial has not been substantiated. Therefore, we decided that the Plan has to retract payment and hold 
you harmless for the single vision lens (V2100) provided on December 14, 2022.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the telephone evaluation and management service by a physician 
(99443) provided on February 2, 2023. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that the service 
should be covered. The Plan denied your request. The Plan says that benefits are not available under the plan 
and has been forwarded to the members behavioral health plan for consideration. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide an explanation of their denial. Therefore, we decided 
that the Plan has to pay for the telephone evaluation and management service by a physician (99443) provided 
on February 2, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88189 billed for date of service August 26, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is not 
enough information to determine the medical necessity of the services. 
 
 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. In this case, there are no medical records available to support the 
billed charges. The file shows that the Plan made multiple attempts to obtain additional information with no 
success. Therefore, we decided that the Plan does not have to pay for procedure code 88189 billed for date of 
service August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH versus short 
term acute care for the enrollee as they will require another three to four weeks to continue weaning down their 
oxygen needs and to transition from their acute illness. The Plan denied your request. The Plan says that 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found given the severity of the enrollee's decompensation, they are reasonably expected to require 
more than 25 days of care thus, the LTACH is warranted, rather than the acute care hospital. The services the 
enrollee needs cannot be provided in the short time frame of the acute care hospital being offered by the Plan.  
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428, A0425), 
provided on February 27, 2023. 
 
You asked the Plan to pay for the non-emergent ambulance transport. You say that the service should be 
covered. The Plan denied your request. The Plan says the enrollee was transported to a non-covered 
destination. In addition, the clinical documentation does not demonstrate that this non-emergency ground 
transportation was medically necessary. The was no evidence to substantiate that she unable to sit in a chair or 
wheelchair or indication that the use of other methods of transportation would be contraindicated or endanger 
her health. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does 
not have to pay for the non-emergent ambulance transport (A0428, A0425), provided on February 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal x-rays provided on February 23, 
2023. 
 
You asked the Plan to waive the copayment for the spinal x-rays. You say that you usually pay at the time of 
service, and were told you did not owe anything. 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 $70 
copayment for outpatient diagnostic tests, including x-rays. 
 
You have been asked to pay a $70 copayment for the spinal x-rays. This item/service falls within the outpatient 
diagnostic tests, including x-rays 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 spinal x-rays provided on February 23, 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 enrollee has the potential to benefit from and is 
willing to participate in the therapy required at an IRF. The Plan denied your request. The Plan says the IRF 
services requested 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 the enrollee 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for an 
LTACH appropriate admission, and you would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says admission to the LTACH is not medically necessary.  
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.