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

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation supports that 
LTACH care is medically necessary and best to manage the enrollee's health care needs. The Plan denied your 
request. The Plan says the records do not show that it is medically necessary to be in an LTACH in place of an 
acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection services rendered on June 16, 
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 each Medicare-covered Part B drug.  
 
Review of the file shows that you received injection services on June 16, 2020. You have been asked to pay a 
20% coinsurance for these services. These services fall within the Medicare-covered Part B drug 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 injection services rendered on June 16, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (HCPCS A4215) provided to the 
enrollee on January 27, 2020. 
 
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 the billed service was not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of HCPCS code A4215 is "Needle, sterile, any size, each." 
 
We find that HCPCS code A4215 is not supported in the medical record. Specifically, the current Physician 
Fee Schedule does not price this code. 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 durable medical 
equipment (HCPCS A4215) provided to the enrollee on January 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone tablets. 
 
You asked the Plan to pre-approve the Prednisone tablets. You say that this is the standard of care, and the 
enrollee is responding well to this medication. The Plan denied your request. The Plan says this medication 
does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone tablets.  
 
Benefits for the Prednisone tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) scan 
(73721) provided on July 1, 2020. 
 
You asked the Plan to waive the copayment for a MRI scan. You say that this should be covered because it was 
in-network. The Plan denied your request. The Plan says this processed 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 $325 
copayment for diagnostic radiology.  
 
You have been asked to pay a $237.06 copayment for a MRI scan. You have been asked to pay the full allowed 
amount because it is less than the copayment specified by the Plan. 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 magnetic resonance imaging (MRI) scan (73721) provided on July 1, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's care can be provided safely at a less intensive setting of 
care. 
 
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. 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. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the wellness visit provided on June 9, 2020. 
 
You asked the Plan to hold you harmless for the wellness visit. You say that this should be covered but was 
billed wrong by the provider, and the provider refuses to re-bill. The Plan denied your request. The Plan says 
that the billing department said you signed an Advanced Beneficiary Notice (ABN) for this service on 
November 9, 2020 and applied a 40% discount. As such, only $98 will be removed from your responsibility. 
 
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. 
 
You were provided with the wellness visit by a contract provider. The file does not show that the Plan provided 
notice that the wellness visit would not be covered. There is mention of a signed ABN; however, it is noted this 
was signed in November 2020 after the date of service and no copy of this document was included in the file as 
evidence you were informed this would not be covered. Under Medicare rules, this means the wellness visit is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the wellness 
visit provided on June 9, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on May 4, 2020. 
 
You asked the Plan to pay for lab tests. You say that this testing was medically necessary and is useful at initial 
diagnosis for a patient with refractory disease. The Plan denied your request. The Plan says that the denial of 
payment for this testing is correct, because this testing was not approved by the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted includes a physician order for the lab 
services billed on this claim. The Plan claims that the ordering provider did not approve of this testing; 
however, the lab requisition form was completed and signed by the ordering physician in according with 
Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of lab tests have 
been met. Therefore, we decided that the Plan has to pay for laboratory testing provided on May 4, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on May 15, 2020. 
 
You asked the Plan to pay for the definitive drug testing. You say that the correct POS code is 11 which is what 
was billed. The Plan denied your request. The Plan says the claim was billed with POS code 81, which is not 
correct as the sample was not obtained directly by the lab. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code reported on a lab claim must 
reflect the location the sample was taken. 
 
Review of the billed claim clearly shows that POS code 81 was reported. The appeal letter itself as well as 
other documentation indicate that the sample was taken in a physician's office, meaning that this code is not 
appropriate. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided 
on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (A9900, E0627). 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that the lift chair is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are 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 the seat lift mechanism. Our reviewer 
says that the requested item is not medically necessary. Our physician reviewer found the documentation does 
not support that a seat lift is likely to affect improvement in the patient's condition or slow deterioration in the 
patient's condition. The records do not indicate that the patient is completely incapable of standing from a chair 
in 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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (A9900, E0627).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 15, 2020. 
 
You asked the Plan to pay for May the ambulance services. You say that you were treated in place by the 
medics. 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 15, 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 May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
12, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not aware there is a 
limit on how often services can be received. The Plan denied your request. The Plan says the services exceed 
the frequency limitations in the benefit plan. 
 
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. The Plan covers the 
comprehensive oral evaluation once every 36 months.  
 
We looked at the file and Medicare rules. The file indicates you last received comprehensive oral evaluation 
services in March 2018. As a result, your benefit for this service was exhausted until March 2021. Based on 
this information, we decided that the Plan's rules for coverage of the comprehensive oral evaluation have not 
been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care service (99214) provided on 
August 6, 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 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). Your contract with the Plan clearly says that you must pay a $65 
copayment for Medicare-covered urgently needed care services.  
 
You have been asked to pay a $65 copayment for the urgent care service provided. 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 urgent care service (99214) provided on August 6, 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 you are still in the hospital, are extremely weak, and 
not eating much. You also say that you still require support to walk and dress yourself. The Plan denied your 
request. The Plan says the request for IRF services 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do 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. Our physician 
reviewer also found that there is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility to verify 
eligibility and obtain proper authorization. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because this provider is out-of-network with the Plan and 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 5, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on 
August 5, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you had to go to another 
dentist office due to COVID-19. You also say that this claim should not be denied. The Plan denied your 
request. The Plan says you have exhausted your benefit coverage for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to 1 comprehensive 
oral exam every 3 years. The record shows that you received a comprehensive oral evaluation on January 22, 
2020, and your comprehensive oral exam benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the comprehensive periodontal evaluation provided on August 5, 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 there is an internal disaster due to lack of 
beds for patients, who in turn are being held in the emergency department. You say that the physician's clinical 
judgement is that the enrollee requires an LTACH level of care and is stable for discharge. The Plan denied 
your request. The Plan says the enrollee is not currently stable for discharge to a lower level of care given 
recent resuscitation need and bilateral pleural effusions that require thoracentesis. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provide 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 he 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. 
 
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.