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

 
We decided that the Plan does not have to pay for the ambulance services provided on May 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell transferring from your electric to 
your manual wheelchair. You say you called requesting a lift assistance not the ambulance service. 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 May 1, 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 on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit (G0463) 
provided February 18, 2020. 
 
You asked the Plan to waive the copayment for the hospital outpatient clinic visit. You say that you do not 
remember having these services. The Plan denied your request. The Plan says the claim processed and the 
correct copayment has been 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 $300 
copayment for each Medicare covered outpatient hospital visit.  
 
You have been asked to pay $120.56 copayment for the hospital outpatient clinic visit. Per the provider your 
current balance is $60. The hospital outpatient clinic visit falls within the outpatient hospital 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 hospital outpatient clinic visit (G0463) 
provided February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee 
on May 13, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation did not include time spent with critically injured patient to verify service billed. 
 
We looked at this coder'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 pay for critical care services (CPT 99291) provided to the enrollee on May 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you thought you were saving a charge for 
everyone by not going to the emergency room visit. 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 18, 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 on March 18, 2020.
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 services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health and home physical 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 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's 
medical status does not currently require intensive rehabilitation physician and nursing oversight only in an 
IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the 
documentation does not support that the enrollee's endurance level can tolerate an 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on 
September 23, 2019. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you refuse to pay this amount 
because you think the out-of-pocket maximum amount had already been reached. The Plan denied your 
request. The Plan says the copayment amount you are being charged is correct. 
 
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 $40 
copayment for physical therapy, up to a maximum out-of-pocket amount of $6,700 for 2019. At the time this 
claim was processed, $6,660 of the $6,700 maximum out-of-pocket amount had been met. This was the final 
claim that applied cost-sharing to your maximum out-of-pocket amount, resulting in a copayment obligation of 
$40 which met the $6,700 total maximum out-of-pocket amount for 2019. 
 
You have been asked to pay $40 copayment for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation 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 a physical 
therapy visit provided on September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the records provided supports the need for the drug 
in dispute. The Plan denied your request. The Plan says the information submitted does not meet the medical 
necessity guidelines for coverage. The Plan says that there is no evidence that the enrollee has tried or cannot 
use Orthovisc and Monovisc. 
 
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 Euflexxa. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drugs 
Monovisc and Orthovisc before they will approve Euflexxa. The enrollee has not tried and failed the required 
drugs. The medical records do not indicate that the required drugs would likely be less effective or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the ambulance service (A0427) provided on February 25, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a 
$225 copayment for each one-way Medicare-covered ground ambulance trip.  
 
The enrollee has been asked to pay a $225 copayment for the ambulance service provided. Based on the plan 
contract, however, the copayment applies to each one-way Medicare-covered ground ambulance transport. 
Paramedic services, which did not include transportation, were rendered to the enrollee on this date by the 
provider in question. Therefore, we decided that the Plan has to waive the copayment for the ambulance service 
(A0427) provided on February 25, 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hyalgan injection for the knee. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not tried and failed conservative therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 requested services. Our physician 
reviewer found that the enrollee has primary osteoarthritis of the left knee. In this case, there is documentation 
that the enrollee has received an intraarticular corticosteroid injection. However, there is no documentation that 
the enrollee has failed a trial of conservative non-pharmacological therapy, such as, exercise or physical 
therapy.  The requested use of Hyalgan is not indicated for the enrollee's condition.  The documentation does 
not support that the requested drug is reasonable or necessary for this 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Hyalgan injection for the knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental core buildup for teeth #19 and 31. 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core 
buildup for teeth #19 and 31.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
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 does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollee's care needs can be met at a lower 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says that acute 
inpatient care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. 
 
The documentation shows that inpatient hospital care was requested from September 2, 2020, forward. 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 inpatient services. Our physician 
reviewer found the enrollee has a history of congestive heart failure, severe cardiomyopathy, diabetes, COPD, 
hypertension, chronic kidney disease stage III, multiple DVTs, breast cancer, LV thrombus, severe tricuspid 
regurgitation, and AFIB. Per the documentation, she was deemed high risk for LVAD back in December of 
2019, and was discharged on palliative isotrope. She presented to the emergency room on September 2, 2020, 
with complaints of dyspnea, nausea, and palpitations. She has an automatic implantable cardioverter 
defibrillator, with no documented defibrillations. She was evaluated and admitted with advance heart failure 
with decompensation requiring titration on inotropes. The review indicates that the record showed that the 
admitting physician reasonably expected the enrollee's care would span two midnights. Therefore, the 
requested inpatient admission was medically reasonable and necessary from September 2, 2020, forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have been met. Therefore, we decided that the Plan has to pre-
approve acute inpatient hospital care.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you do not have information on the enrollee's 
insurance requirements. The Plan denied your request. The Plan says the enrollee's plan requires utilization of 
network providers, and authorization for certain services. 
 
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, and referring provider in this case are not a network providers with the Plan. The Plan 
has network providers available who can provide the lab services at issue in this appeal. The Plan did not pre-
approve the services at issue. We found no exception that would require the Plan to pay for these OON 
services. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 26, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on February 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan indicates that clinical documentation was reviewed to make its 
decision. The provider also indicates in the appeal letter that records were submitted to the Plan. Without 
medical records, the Plan?s denial cannot be substantiated. Therefore, we decided that the Plan has to pay for 
the services provided on February 13, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary to increase 
mobility, independence, and safety both inside and outside of the home. The Plan denied your request. The 
Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal that you have a personal mobility deficit that impairs participation in MRADLs 
in the home. Your mobility deficit is currently helped by a cane and walker. There is no evidence of an 
objective home assessment with measurements to evaluate that you can safely maneuver the PMD within 
rooms/spaces within the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on November 26, 2019. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the claim. The 
Plan denied your request. The Plan says the service has been previously processed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim are denied. 
 
We looked at the file and Medicare rules. The documentation shows that the anesthesia services at issue were 
processed and paid on a previously submitted claim. Based on this information, we decided that Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract removal post-operative care (66984) provided on 
December 30, 2019. 
 
You asked the Plan to pay for the post-operative care. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation does not support the service 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 66984-55 is  extracapsular cataract removal with 
insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and 
aspiration or phacoemulsification). Modifier -55 is for post-operative management only. 
 
We asked our coder 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 post-operative care. Our reviewer says that CPT code 
66984-55 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
documentation does not include post of follow up care for the billed date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the post-operative care have not been met. Therefore, we decided that the Plan 
does not have to pay for cataract removal post-operative care (66984) provided on December 30, 2019.