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

We decided that the Plan does not have to pre-approve twenty-five (25) additional routine transportation trip miles.
You asked the Plan to pre-approve additional routine transportation trip miles. You say that you have an impacted wisdom tooth. The Plan denied your request. The Plan says this request exceeds your plan benefits limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The 51st mile and beyond is not a covered benefit. Each one-way trip must not exceed fifty (50) miles of driving distance. A trip is one-way transportation; a round trip is two (2) trips. Therefore, we decided that the Plan does not have to pre-approve twenty-five (25) additional routine transportation trip miles.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
August 2, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for this bill because you went to the emergency room but did not receive treatment. The Plan
denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $110
copayment for each Medicare-covered emergency room visit.
You have been asked to pay a $110 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The record shows you were seen by a nurse practitioner.
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 emergency room visit provided on August 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wheelchair seat cushion rendered on
July 25, 2020.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the coinsurance was applied 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 20%
coinsurance for Medicare-covered durable medical equipment and related supplies.
Review of the file shows that you received a wheelchair seat cushion on July 25, 2020. You have been asked to
pay a 20% coinsurance for these services. These services fall within the Medicare-covered durable medical
equipment and related supplies 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 coinsurance for
the wheelchair seat cushion rendered on July 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee presented due to shortness of breath, cough and fever. She was found to be hypoxic with saturation of 87%. Initially placed on a 5 L nasal cannula which later progressed to a non-rebreather mask. The enrollee was also found to be positive for Covid-19 and was given Remdesivir. The enrollee is still on BiPAP at 100%. There is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ninety-six (96) additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you have to go to dialysis. The Plan denied your request. The Plan says additional trips above your benefit allowance of 40 trips/calendar year are not covered by Medicare or your health plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The 41st trip and beyond is not a covered benefit. The health plan contract says that enrollees must pay a $0 copayment for forty (40) one-way trips to plan-approved locations every year. Therefore, we decided that the Plan does not have to pre-approve ninety-six (96) additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coflex interlaminar/interspinous process
stabilization/distraction device (CPT Code 22867).
You asked the Plan to pre-approve the services. You say that you need this surgery as it is medically necessary.
The Plan denied your request. The Plan says the clinical value and effectiveness of Coflex
interlaminar/interspinous process stabilization/distraction device in the setting of lumbar spinal stenosis have
not been demonstrated in the peer-reviewed literature.
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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Coflex device remains experimental. More research is needed to show safety and efficacy.
There is no spinal instability documented. Hardware not needed.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Coflex interlaminar/interspinous process stabilization/distraction device (CPT Code
22867).
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 stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for lumbar decompression surgery for spinal stenosis. Medical conditions are stable. There are no
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a
reasonable expectation that this patient 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says payment for a SNF level of care could not be made if the patient needs an 
intermittent rather than daily skilled service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 are diabetic and in need of 24 hour care, as you 
are prone to fracture another bone. You say that you need to be at rehab to get stronger. You say that your 
orthopedic specialists advised that rehab services in an IRF are appropriate so you can receive aggressive care. 
The Plan denied your request. The Plan says the records do not show that the enrollee needs to be seen by a 
rehab doctor 3 times per week. The Plan says that the enrollee does not need an intensive team for care and that 
the care needed can be provided 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 above. 
 
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. The enrollee 
does require physical therapy and occupational therapy services but, based on the medical records provided, the 
enrollee does not require an intensive inpatient rehabilitation therapy program. There is no documentation that 
the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate in this case. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for presumptive drug tests by chemistry analyzers (80307) and definitive 
drug tests utilizing one drug identification method (G0482). 
 
You asked the Plan to pay for drug tests. You say that you conducted the testing that was ordered by the 
referring provider in good faith. The Plan denied your request. The Plan says that you must get care from in-
network providers. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for drug tests by a Plan contracted provider. The file does not show that the plan 
provided notice that drug tests would not be covered. Under Medicare rules, this means drug tests is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for presumptive drug tests by chemistry 
analyzers (80307) and definitive drug tests utilizing one drug identification method (G0482).  
 
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 pay for the medical services provided on August 9, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician visit. You say that the provider said they accept your insurance. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and prior authorization was not obtained. 
 
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 has network providers 
available who can provide 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 the medical services provided on August 9, 2019 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the microprocessor control unit (Q0481) provided on May 
28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for microprocessor control unit. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services by an out-of-network 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 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 has network providers 
available who can provide 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 the microprocessor control unit (Q0481) provided 
on May 28, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0427) provided 
January 21, 2020. 
 
You asked the Plan to waive the copayment for the Ambulance Transport. You say that the copayment is a 
hardship and should be waived. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 Ambulance Services.  
 
You have been asked to pay a $250 copayment for the Ambulance Transport. The Ambulance Transport falls 
within the Ambulance 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 copayment for 
an Ambulance Transport (A0427) provided January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 30, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
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 March 30, 2020. 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 the ambulance services provided on March 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient practitioner services provided from November 21, 
2019, to November 22, 2019. 
 
You asked the Plan to pay for practitioner services. You say that the enrollee was discharged from hospice for 
these dates of service. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because Original Medicare continues to cover the enrollee through the end of the month when the 
enrollee revokes or is discharged from hospice alive. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 21, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient practitioner 
services provided from November 21, 2019, to November 22, 2019.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided on April 24, 2020 
through May 23, 2020. 
 
You asked the Plan to pay for SNF. You say that the services were medically necessary. The Plan denied your 
request. The Plan says that the enrollee did not have daily skilled nursing or rehabilitation needs that required 
an inpatient stay at a SNF, and appropriate care could have been rendered/obtained at a lower level of care, or 
in the home. 
 
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. Specifically, the Plan has not forwarded medical records to the IRE for review. 
The file indicates that the Plan requested and received medical records in this case. The file also indicates that 
the provider in this case is a Plan contracted provider. The medical records are therefore, considered to be 
within the Plan's control. Without medical records, the denial is not substantiated, and we must find in your 
favor. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided on 
April 24, 2020 through May 23, 2020.  
 
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.