Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving the medically necessary 
care in the currently setting. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that they 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care provided from August 2, 2023, to August 6, 
2023. 
 You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
during the period in question are coverable. The Plan denied your request. The Plan says the enrollee no longer 
required daily skilled services at a SNF level of 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 pay for the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 pay for the SNF care provided from August 2, 2023, to August 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve geniculate artery embolization (36246, 36247). 
 
You asked the Plan to pre-approve geniculate artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 geniculate artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested services are experimental for knee pain treatment. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of geniculate artery embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve geniculate artery embolization (36246, 36247).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on August 
23, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you do not understand 
why the services are not covered. The Plan denied your request. The Plan says the Medicare ambulance benefit 
is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on August 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health personal care aide (99499). 
 
You asked the Plan to pre-approve a home health personal care aide. You say that the services are 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. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home health personal care aide have not been met. Specifically, we find that the services at issue 
in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
a home health personal care aide (99499).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on July 19, 2023. 
 
You asked the Plan to pay for the home visit evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all of their patients, which should also cover for the medical treatments. 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 home visit 
evaluation provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation stay provided on June 14, 2023. 
 
You asked the Plan to pay for the observation stay. You say that you are requesting reconsideration for the 
services provided. 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 observation stay 
provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial colectomy with an ileocolostomy provided on 
February 20, 2023. 
 
You asked the Plan to pay for a partial colectomy with an ileocolostomy. You say that the services were 
medically necessary. 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 a partial colectomy with 
an ileocolostomy provided on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - full cast high noble metal tooth #25 (D2790). 
 
You asked the Plan to pre-approve crown - full cast high noble metal tooth #25. You say that this is medically 
necessary. The Plan denied your request. The Plan says services to restore tooth structure damaged from 
abrasion, attrition, erosion or abfraction are not covered. Your x-rays show that the lower anterior teeth have 
been worn down from abrasion, attrition, and erosion. 
 
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. The Plan covers crown - full 
cast high noble metal tooth #25 when the services are medically necessary and reasonable.  
 
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 crown - full cast high noble metal tooth #25. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the 
records provided this tooth has a guarded to poor prognosis and a crown is not recommended for the tooth. 
D2790 is not medically reasonable or necessary. A tooth that has compromised supporting structures is not a 
long-term stable tooth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown - full cast high noble metal tooth #25 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve crown - full cast high noble metal tooth #25 (D2790).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on June 27, 2023. 
 
You asked the Plan to pay for the wound care supplies. 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 wound care supplies 
provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Caire freestyle comfort model #AS200-1 portable 
oxygen concentrator. 
 
You asked the Plan to pre-approve a Caire freestyle comfort portable oxygen concentrator. You say that the 
item is necessary. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Caire freestyle comfort portable oxygen concentrator. Therefore, we decided that the Plan does not have 
to pre-approve a Caire freestyle comfort model #AS200-1 portable oxygen concentrator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cystourethroscopy procedure provided 
on March 16, 2023, to June 12, 2023. 
 
You asked the Plan to waive the copayment for each cystourethroscopy procedure. You say that you were 
unaware of the copayments. 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 $250 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $250 copayment for each cystourethroscopy procedure. This item/service falls within the outpatient surgery, including services provided at ambulatory surgical centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe 
is $500 ($250 copayment x 2 procedures = $500). Therefore, we decided that the Plan does not have to waive 
the copayment for each cystourethroscopy procedure provided on March 16, 2023, to June 12, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve kidney transplant evaluation. 
 
You asked the Plan to pre-approve kidney transplant evaluation. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 kidney transplant evaluation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record provided indicates that the enrollee is considered an excellent 
candidate by the pre-transplant nephrology clinic and deemed to be a low-risk candidate from psychosocial 
perspective. The record provided establishes the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are satisfied. The requested service 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 kidney transplant evaluation have not been met. Therefore, we decided that the 
Plan has to pre-approve kidney transplant evaluation.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc NP. 
 
You asked the Plan to pre-approve VIA Disc NP. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 VIA Disc NP. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy. Therefore, the request is deemed not medically 
reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA Disc NP.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the enrollee has been unresponsive to aggressive 
topical therapy. 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 Dupixent.  
 
Benefits for Dupixent 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided from June 9, 2023, to June 10, 2023. 
 
You asked the Plan to pay for the hospital care. You say that the services provided were medically necessary. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital care provided from June 9, 2023, to June 10, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 1, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not on hospice on this 
date. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on June 1, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 18, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the claim was filed timely and should be 
processed. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a second opinion to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a second opinion to be provided by an out-of-network (OON) provider.