Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs and a hospital outpatient visit 
provided on February 28, 2023. 
 You asked the Plan to pay for the medication and a hospital outpatient visit. You say that this should be 
covered. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan and there is a $400 copayment for out of network hospital outpatient services. 
 
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 pay for self-administered drugs and a 
hospital outpatient visit provided on February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and spinal x-ray 
provided on January 30, 2023. 
 
You asked the Plan to waive the copayments for the specialist office visit and spinal x-ray. You say that there is 
an error with this claim. 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 $5 
copayment for primary care provider office visits. Your contract with the Plan also clearly says that you must 
pay a $45 copayment for each x-ray service. You have been asked to pay a $5 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have been asked to pay $39.60, which is less than the 
standard $45 copayment for the spinal x-ray. This item/service falls within the outpatient diagnostic tests and 
therapeutic 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. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office 
visit and spinal x-ray provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin cleanser purchased on February 6, 2023. 
 
You asked the Plan to pay for the skin cleanser. You say that the back of the label reads this cleanser can be 
used with or without water, and your doctor recommended it for rosacea and sensitive skin. The Plan denied 
your request. The Plan says this is an ineligible expense under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and skin 
cleanser is an OTC item. However, your plan offers a supplemental benefit for specific OTC items. Skin 
cleanser is not listed as a covered OTC benefit under the supplemental reimbursement program. Therefore, we 
decided that the Plan does not have to pay for the skin cleanser purchased on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a group 1 standard POV. You say that you have no way of getting around or 
getting out of bed. You also say that you feel that you qualify for a power chair, and you cannot use any other 
method to get around. The Plan denied your request. The Plan says your request is not medically necessary 
because your records show you do not have documentation that your home provides adequate access between 
rooms, maneuvering space, and surfaces for the operation of a POV. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the criteria must show that the beneficiarys 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power 
wheelchair that is provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 1 standard POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 1 standard power operated vehicle (POV) (K0800).
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 lives at home alone and inpatient 
rehabilitation is the only chance this enrollee may have at returning to their prior level of function or higher and 
regaining their quality of life. You say this enrollee's needs cannot be met a lower level of care. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare 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 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. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Ondansetron have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Ondansetron.
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 continued admission to a SNF is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for continued SNF care. 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: 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 an alternate level of care.  
 
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 enrollee has no complex functional impairments or active medical 
comorbidities that would require an acute hospital inpatient stay with an interdisciplinary approach. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0088, G0068, S9328. 
 
You asked the Plan to pay for procedure codes G0088, G0068, S9328. You say that the services are necessary. 
The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes G0088, G0068, S9328 have Status Indicators of I and X on the Physician Fee 
Schedule. This means that procedure codes G0088, G0068, S9328 are not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of procedure codes G0088, G0068, S9328 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes G0088, 
G0068, S9328.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan.  
 
You asked the Plan to pre-approve the PET scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our physician reviewer 
found the service 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 the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need more intensive care in an inpatient 
rehabilitation facility to recover. The Plan denied your request. The Plan says you do not meet the criteria for 
admission to an Inpatient Rehabilitation Facility. 
 
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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support this expedited 
appeal. The Plan denied your request. The Plan says you do not meet the Medicare 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lower extremity vascular surgery and lower gastrointestinal bleeding. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. While 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. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Octagam. 
 You asked the Plan to pre-approve Octagam. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Octagam. Our reviewer says that 
Octagam is not medically necessary. Our physician reviewer found that there is no indication that the enrollee 
has tried and failed the required drug Privigen. Also, there is no indication that the Plan's required drug would 
likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Octagam have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Octagam.
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 you are requesting an expedited appeal 
of the LTACH denial. The Plan denied your request. The Plan says you do not meet the guidelines for care in 
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 you have had a complicated hospital course and still have ongoing acute medical 
issues requiring acute care services. You continue to receive acute care services, and these have not been 
denied by the Plan. The medical record does not indicate that you require services that you are not currently 
receiving but that would be available at the LTACH 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a service dog (S5199). 
 
You asked the Plan to pre-approve a service dog. The Plan denied your request. The Plan says the provided 
documentation indicates that the enrollees dog is an emotional support animal thus not meeting the definition 
of a support animal by the ADA. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a Medicare Advantage (MA) plan may offer 
coverage of a supplemental benefit only if it is medically necessary and additional to the benefit covered by 
original Medicare. 
 
We looked at the file and Medicare rules. The Plan is using the ADA definition of a service dog that is 
individually trained to do work or perform tasks for people with disabilities. The work or task a service dog has 
been trained to provide must be directly related to the persons disability. Dogs whose sole function is to 
provide comfort or emotional support do not qualify as service animals under the ADA. Based on this 
information, we decided that Medicare rules for coverage of a service dog have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a service dog (S5199).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant placement (D6010), and a bone graft at time of 
implant placement (D6104), provided on March 2, 2023. 
 
You asked the Plan to pay for D6010 and D6104. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says the rendered dental services are not covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant 
placement (D6010), and a bone graft at time of implant placement (D6104), provided on March 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 16, 2022, to August 3, 
2022. 
 
You asked the Plan to pay for the home health services. You say that even though we filed the notice of 
admission beyond the deadline, we should still receive payment for the claims. The Plan denied your request. 
The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 16, 2022. The NOA was not received by the Plan until August 19, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on July 16, 2022, to August 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 24, 2022, to 
November 22, 2022. 
 You asked the Plan to pay for the home health services. You say to please see proofs of the NOA submission 
and reprocess the claim for payment. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 24, 2022. The NOA was not received by the Plan until February 
14, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on October 24, 2022, to November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pre-approve massage therapy.