Persius/hicric huggingface dataset:
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires or 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 acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the 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 based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. There is concern that the patient will not be able to fully participate in and benefit from 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unusual travel (eg, transportation and escort of patient) 
(CPT Code 99082). 
 
You asked the Plan to pre-approve the services. You say that you are requesting coverage for travel and 
lodging in order to receive services with a non-participating provider. The Plan denied your request. The Plan 
says reimbursement for Travel and lodging isn't available. The Plan states that you will be responsible for these 
expenses. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. It has been confirmed that you are 
not receiving transplant services. The services being rendered are Physical and Occupational Therapy. 
Therefore, we decided that the Plan does not have to pre-approve unusual travel (eg, transportation and escort 
of patient) (CPT Code 99082).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility visit (99304) provided on July 14, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the initial nursing facility visit. You say that you are the only provider providing 
podiatry services in this nursing home. 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 initial nursing facility visit (99304) provided 
on July 14, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99213), electrical stimulation 
(G0283), and therapeutic procedures (97110) provided from June 24, 2020, to July 1, 2020. 
 
You asked the Plan to pay for a chiropractic office visit, electrical stimulation, and therapeutic procedures. You 
say that these services should be covered. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99213), electrical stimulation (G0283), and 
therapeutic procedures (97110) provided from June 24, 2020, to July 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable supplies (A0398) provided on January 18, 2020. 
 
You asked the Plan to pay for the disposable supplies. You say that you would like reconsideration because this 
claim was denied inappropriately. The Plan denied your request. The Plan says services and supplies are 
included in the base ambulance service rate. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services is included in the 
fee schedule payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable supplies have not been met. Specifically, payment for these supplies is included in 
the base ambulance fee schedule payment. Therefore, we decided that the Plan does not have to pay for 
disposable supplies (A0398) provided on January 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on April 21, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that your plan was updated 
incorrectly. The Plan denied your request. The Plan says 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 a $50 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $50 copayment for specialist services. Specialist services fall within the 
physician/practitioner services/specialist 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 specialist services provided by a participating provider on April 21, 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 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires 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 acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99348) provided on August 19, 2019. 
 
You asked the Plan to pay for the home visit. 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 services 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 99348 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99348 is not supported in the record. Specifically, the record does not indicate that the 
physician was present in the member's home. Based on this information, we decided that Medicare rules for 
coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for a 
home visit (99348) provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroutpatient hospital services provided to the enrollee on June 4, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthese services required prior authorization.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 Plandoes not haveto pay foroutpatient hospital services provided to the enrollee on June 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office outpatient visit (99213) provided on June 18, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you were unaware prior authorization was required for this service.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered 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 forthe office outpatient visit (99213) provided on June 18, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cochlear implant. 
 
You asked the Plan to pre-approve the cochlear implant. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the records do not include a hearing test to 
determine the levels of hearing loss. 
 
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 cochlear implant. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not include an audiogram, or a test with the member wearing 
hearing aids. The criteria states that the member's pure tone average should be 70dB or greater at 500 Hz, 1000 
Hz, and 2000 Hz. There should also be limited or no benefit from hearing aids with 40% correct in the best-
aided listening condition. The member's audiogram numbers do not meet this criteria in either ear. 
 
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 cochlear implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cochlear implant.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from June 13, 
2020, to June 14, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges 
because you stayed overnight. The Plan denied your request. The Plan says the claims were processed 
correctly, and you are being charged the correct 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 $90 
copayment for emergency care. 
 
The record shows that you received emergency care on June 13, 2020, to June 14, 2020. The record indicates 
you were admitted under observation, not inpatient. Therefore, you are responsible to pay the $90 copayment.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided from 
June 13, 2020, to June 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous immune globulin injections (J1459) provided on 
May 26, 2020. 
 
You asked the Plan to pay for intravenous immune globulin injections. You say that this should be covered. 
The Plan denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that intravenous immune globulin (IVIG) is covered 
if the patient has a diagnosis of primary immune deficiency disease. 
 
We looked at the file and Medicare rules. The record does not show the enrollee has a diagnosis of primary 
immune deficiency disease. Based on this information, we decided that Medicare rules for coverage of 
intravenous immune globulin injections have not been met. Therefore, we decided that the Plan does not have 
to pay for intravenous immune globulin injections (J1459) provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit (99336) provided on June 3, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that medically necessary services in good faith. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered 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 domiciliary visit (99336) provided on June 3, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for 4 specialist office services (99202, 97597, 
99212) on June 17 to July 22, 2020. 
 
You asked the Plan to waive the copayments for 4 specialist office services. You say that you should not pay 
for these charges because they were based off a COVID-19 diagnosis. The Plan denied your request. The Plan 
says the correct copayment were 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 $15 
copayment for each specialist office visit.  
 
You have been asked to pay $60, or a $15 copayment for each one of 4 specialist office services. Specialist 
office services fall within the "Physician/Practitioner services, including doctors office visits" benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for 4 specialist office services (99202, 97597, 99212) on June 
17 to July 22, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for continued inpatient hospital services for the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the discharge is being appealed. The 
Plan denied your request. The Plan says that there are no acute care needs. 
 
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. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for continued inpatient hospital services for the enrollee.  
 
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.