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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs are custodial in nature. 
 
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 enrollee is generally medically stable, with no evidence of medical or nursing 
needs in an IRF. The enrollee's current functional status does not require the IRF level of therapy. There is no 
evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. IRF admission is not medically necessary for this enrollee, and also 
does not meet the CMS coverage criteria. Her rehab needs can be safely and effectively met in an alternate, less 
intense setting such as in an SNF. 
 
 
 
 
 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided April 10, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the service at issue is not supported in the medical record. Specifically, Indian Health Service 
providers are required to bill any services under revenue code 0510 (clinic visit) on Type of Bill 13X (hospital 
outpatient). The services at issue were not billed as required. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services provided April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
September 23, 2019. 
 
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied 
your request. The Plan says the enrollee did not have prior authorization for out of network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network physician services provided to the enrollee on 
September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on 
May 6, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that these visits are not pre-
scheduled and therefore an authorization was not obtained prior to the services provided. The Plan denied your 
request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment 
has been correctly denied. 
 
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 subsequent nursing facility visit (99309) 
provided on May 6, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chemical destruction of incompetent vein of arm or 
leg (36482) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the chemical destruction of incompetent vein of arm or leg. You say that 
you would like this claim pre-approved for payment. The Plan denied your request. The Plan says your 
treatment can be safely rendered in-network. 
 
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 
the chemical destruction of incompetent vein of arm or leg (36482) to be provided by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99335) provided 
on February 25, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient assisted living visit (99335) 
provided on February 25, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services (73100, Q0092, R0070) provided 
on March 6, 2020. 
 
You asked the Plan to pay for the mobile x-ray services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the mobile x-ray services (73100, Q0092, R0070) provided on March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 25, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physicians intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on February 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 24, 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 April 24, 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 by you on April 
24, 2020.
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 needs rehab so that she can get back to 
her normal life. You say that the enrollee needs rehab in order to learn to work again, and her condition will 
only get worse from not being able to move. The Plan denied your request. The Plan says the guidelines for 
coverage of IRF care have not been met. The Plan says that, at the present time, the enrollee's medical care is 
ongoing and the amount of therapy being received is appropriate to meet her needs. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for low back pain with acute compression fractures L3-L5. The enrollee's medical problems are 
stable and there are no identified problems that need inpatient medical management. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record 
supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Orthovisc injection (J7324). 
 
You asked the Plan to pre-approve an Orthovisc injection. 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 follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be covered when specific criteria is 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 an Orthovisc injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the enrollee does not have 
documented trials of either a home exercise program or physical therapy (PT). He also does not have a trial of 
nonsteroidal anti-inflammatory drugs (NSAIDs) documented or a reason why it would be inappropriate. He 
does not meet the coverage criteria and therefore, the request is considered not medically reasonable or 
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 an Orthovisc injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Orthovisc injection (J7324).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you are too weak to care for yourself. The Plan 
denied your request. The Plan says you do not need daily skilled nursing or therapy services. 
 
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 SNF services. Our physician reviewer 
found that from a nursing perspective, you received oral medications, and had stable vital signs. There are no 
identifiable skilled nursing service needs. Regarding rehab services, you are at a contact guard to minimal 
assist level with functional mobility. You often declined therapy intervention. There are no identifiable skilled 
therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular procedure services provided on May 16, 
2018. 
 
You asked the Plan to pay for the cardiovascular procedure services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the cardiovascular procedure services was not filed until December 14, 2019. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the cardiovascular procedure services provided on 
May 16, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a foot tissue debridement (11042) 
performed on February 20, March 3, March 12, and March 25, 2020. 
 
You asked the Plan to waive the copayment for a foot tissue debridement. You say that you cannot pay these 
charges. 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 $395 
copayment for Medicare-covered surgery provided at an outpatient hospital.  
 
You have been asked to pay $1,497.96, or a $374.79 copayment for 4 dates of service, for a foot tissue 
debridement. A foot tissue debridement falls within the "Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that 
you have been asked to pay less than the full copayment 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 a foot tissue debridement (11042) performed on February 
20, March 3, March 12, and March 25, 2020.  
 
Your complaint about not receiving satisfactory responses from the Plan?s customer service department is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery and connective tissue graft provided on 
January 23, 2020. 
 
You asked the Plan to pay for the osseous surgery and connective tissue graft. You say that you were never 
informed that these procedures would no longer be covered. You say that the denial of covered services is 
invalidated. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 the 
osseous surgery and connective tissue graft provided on January 23, 2020.
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 acute rehab will increase the enrollee's strength. The 
Plan denied your request. The Plan says the enrollee has made no measurable progress in therapy. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for pneumonia. His medical problems are stable. The 
complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation 
that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. The medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) and the anesthesia (D9211) provided 
on May 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the dentist was out of 
network. You say that your in network dentist referred you for the service. You also say that you were not 
aware that this group had opted out of Medicare. The Plan denied your request. The Plan says the provider in 
this case has chosen to opt out of Medicare. The Plan says that provider who have opted out of Medicare are 
not permitted to send claims to Medicare or Medicare Advantage plans. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the extraction (D7210) and the anesthesia (D9211) provided on May 22, 2020.