Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services (97164 and 97161) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you fell and broke your arm, had 
surgery, and would like to get started with treatment right away before your arm gets worse.  The Plan denied 
your request. The Plan says the requested service does not meet the definition of emergent or urgent care.  
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the 
documentation does not support that you require the out-of-network services on an urgent or emergent basis. 
Additionally, there is no clear medical reason why you are unable to continue receiving services within your 
network area. 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve physical therapy (PT) services (97164 and 97161) to be provided by 
an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from June 15, 2023, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. Medicare rules say that for Medicare 
to consider coverage and payment for any item or service, the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. 
 
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 provided there is no documentation that the enrollee requires the services on an 
inpatient basis, only in a skilled nursing facility setting. Records support that services in the long-term care 
facility on a part time basis are appropriate in this case. Furthermore, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SNF care have been met.  
 
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 the continuation of skilled nursing facility (SNF) care from June 15, 2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 
and segmental trunk, full leg, and full arm appliances. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that the 
enrollee has failed at least four weeks of conservative care with a basic lymphedema pump. Additionally, the 
records do not support that the enrollee has physical findings consistent of truncal, abdominal, or chest edema. 
The criteria for coverage are not met and the PCD and appliances are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) coded E0652 and segmental trunk, full leg, and 
full arm appliances.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 3, 2023, to January 12, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are unable to afford 
the cost share applied. 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 $230 
copayment per day for days 1 to 5 and $0 for days 6 to 90 for inpatient hospital care.  
 
 
  You have been asked to pay $1,150 for an inpatient hospital stay ($230 per day x 5 days = $1,150). This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay provided from January 3, 2023, to January 12, 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have any parental medications, complex wound care or nutrition 
given via a feeding tube. The enrollee was medically stable without any acute exacerbations of chronic medical 
problems. The enrollee's physical function was at or near their baseline and the enrollee could have received 
further services at a lower level of care. An admission to the nursing facility at a skilled level of care for 
inpatient skilled services was 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with multiple 
power options and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee 
does not have medical need for the multiple power options available with the requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
has a neurologic disorder with functional deficits. The documentation does not indicate that the enrollee has 
any pressure injuries, requires intermittent catheterization of the bladder, or has spasticity that would 
necessitate power tilt or recline. Although the enrollees condition may meet criteria for a PWC, the criteria for 
this specifically requested PWC with multiple power options including power tilt and recline are not met. As 
the PWC base is not medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) with multiple power options 
and accessories.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 medical records relating to the requested Dexcom G6 
sensor. Without the necessary medical records, we are unable to determine if the coverage criteria has been 
met. Therefore, we decided that the Plan has to pre-approve a Dexcom G6 sensor.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a CT scan provided on January 25, 2023. 
 
You asked the Plan to waive the cost share for a CT scan. You say that you should not have to pay the 
copayment for a mandatory scan. 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, up to $75 per day for Medicare-covered diagnostic radiology services. 
 
 
  You have been asked to pay $75 for a CT scan. This item/service falls within the outpatient diagnostic tests 
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 cost share for a CT scan provided on January 
25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a dermatologist to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the records received do not indicate that you have an emergent or urgent medical 
condition or are in need of specialized service(s) that are not available in the network. You have an HMO 
(Health Maintenance Organization) plan. There are in-network provider(s) within a reasonable distance from 
your location that can 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 
an office visit with a dermatologist to be provided 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 home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). The records document that 
the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-EPAP (AE), which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Medicare does not cover a ventilator for this use. The services are therefore not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to see an ear, nose and throat (ENT) allergy 
specialist to be provided by an out-of-network (OON), out-of-area (OOA) provider. 
 You asked the Plan to pre-approve office visits with a specialist. You say that the enrollee visits her family 
frequently in Kentucky. The enrollee experiences a lot of shortness of breath and coughing for her first few 
days on her trip. The enrollee is looking to be seen in Kentucky with the hope that they can figure out the 
allergens and allow her to enjoy time with her family without worsening. The Plan denied your request. The 
Plan says the EOC states that when the enrollee is outside the service area and cannot get care from a network 
provider, the plan will cover urgently needed services that she can get from any provider.  
 
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. Medicare also says 
that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of 
the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The notes from the enrollees 
doctor show that she is following with a local allergist with findings of allergy reactions to grass, ragweed, 
pigweed, penicillin, cat, cockroach, dust mites, horse, feathers, hamster and mouse. In addition, the enrollee is 
currently being treated for her allergies. The Plan has network providers available who can provide the 
items/services at issue in this appeal. Urgently needed services are defined as non-emergency, unforeseen 
(unexpected) medical illness, injury, or condition that requires immediate medical care. As the enrollee resides 
in the Buffalo area and travels to Kentucky monthly, the request to see a specialist is not for unforeseen or 
emergent care but for foreseen care (expected) care. 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 office visits to 
see an ear, nose and throat (ENT) allergy specialist to be provided by an out-of-network (OON), out-of-area 
(OOA) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve continued use of a home ventilator. You say that you need this device to 
treat your chronic obstructive pulmonary disease. You have been using this service for more than a year and 
you need the machine to help with your breathing. The Plan denied your request. The Plan says the doctor has 
prescribed a ventilator to help with breathing at various times of the day (night and day) because of your lung 
disease. Your chart shows that you are not using this breathing machine regularly and Medicare does not cover 
this machine if it is not used regularly. 
 
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. 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 continued use of a home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have COPD, 
obstructive sleep apnea, and narcolepsy. You currently have a home ventilator for an unknown duration.   
Pulmonary function tests reportedly showed severe obstruction in 2021, although no data is provided. Case 
notes indicate that you are not using the device regularly, and the clinical note from June 27, 2023, says you are 
having difficulty tolerating the device. However, the records do not include any compliance data. There is no 
documentation of chronic CO2 retention. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. If you do have chronic CO2 retention, it appears the respiratory needs could be met with BiPAP with 
AVAPS during sleep, if compliance can be achieved. Medicare does not cover a home ventilator when used 
with settings that can be provided with BiPAP, or when the device is not being used enough to be effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a home ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve dialysis services to be provided by the requested out-of-network provider. 
You say that the services are medically necessary. The Plan denied your request. The Plan says we are beyond 
continuation of care requirements at this time, and we have in-network dialysis facilities in the area that the 
member should utilize.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dialysis 
services to be provided by the requested out-of-network provider.