Persius/hicric huggingface dataset:
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the 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 respiratory failure and COVID 19 pneumonia. The enrollee's medical conditions are stable. 
There are no medical needs requiring inpatient admission. 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. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that 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 waive the copayment for hearing services provided on February 19, 
2020. 
 
You asked the Plan to waive the copayment for hearing services. You say that you disagree with the charges 
and feel that you should owe nothing. 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 $75 
copayment for out-of-network hearing services.  
 
You have been asked to pay the allowed amount of $71.28, which is less than the $75 copayment for hearing 
services. Hearing services fall within the hearing 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 hearing services provided on February 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation and set up of a portable x-ray (R0070 and 
Q0092) provided on August 3, 2020. 
 
You asked the Plan to pay for the transportation and set up. You say that you would like reconsideration 
because this service was billed correctly. The Plan denied your request. The Plan says POS code 32 should be 
used with services for beneficiaries in a non-covered stay. 
 
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 CPT codes R0070 and Q0092 are not supported in the record. Specifically, this claim has been 
billed with POS 31 indicating that this member was in a Part A SNF stay. If the member is in a Part A SNF 
stay, the transportation and set up costs are subject to consolidated billing and not separately billable to 
Medicare Part B. Of note, the Plan indicates that there is no record of authorization for SNF services approved 
for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the 
transportation and set up have not been met. Therefore, we decided that the Plan does not have to pay for 
transportation and set up of a portable x-ray (R0070 and Q0092) provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on June 19, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says payment for this service would be included in the prospective PPS payment 
to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic testing and services as part of a pre-
operative examination and/or outpatient procedure or surgery, are not separately covered apart from the 
Medicare prospective payment. 
 
Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been 
met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on June 19, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item has deluxe features that exceed medical need. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the MyoPro Orthosis is not the most appropriate available supply or level of service for the enrollee in 
question considering potential benefits to the enrollee. It is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes for post stroke hemiparesis. 
The MyoPro is not in widespread use based on scientific evidence and not the standard of care for post stroke 
hemiparesis. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long 
term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
September 12, 2020, to September 15, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not believe 
you received inpatient hospital care only observation care. The Plan denied your request. The Plan says the 
services provided were inpatient hospital care and the copayment 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 $250 
copayment for inpatient hospital care.  
 
You have been asked to pay a $250 copayment for the inpatient hospital services. the inpatient hospital services 
falls within the inpatient hospital 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 
the inpatient hospital services provided September 12, 2020, to September 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Next Generation lab testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says this test is only FDA-approved for lung cancer, not breast cancer. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to have breast cancer, which was diagnosed in 2015, and has since metastasized. Panel 
testing, inclusive of testing that is not related to breast cancer or for which there are no associated therapies, is 
not medically necessary or reasonable. The documentation does not support that the requested panel testing is 
medically necessary or reasonable. 
 
 
 
 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Next Generation lab testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that you can be treated in a lower level of 
care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. You 
do not appear to require inpatient mental health treatment as you are not a danger to yourself or others, have no 
auditory hallucinations but do have visual hallucinations although nonspecific while being cooperative with 
treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient 
psychiatric hospital services. 
 
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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0427, A0425) provided on June 4, 2020. 
 
You asked the Plan to pay for ambulance services. You say that this was billed correctly. The Plan denied your 
request. The Plan says that the provider type submitted  is not valid for the services billed. 
 
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 case file does not include a rationale as to why the hospital is not eligible to 
provide ambulance services, and there is an error on the remittance advice in regards to the rendering provider. 
Therefore, we decided that the Plan has to pay for ambulance services (A0427, A0425) provided on June 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary level referral for an audiology evaluation and 
testing. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information does not show a need for tertiary level of care. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you would benefit from a hearing test given her previous diagnosis of hearing loss. However, it does not 
need to be performed with a tertiary level audiologist. It can be performed with a non-tertiary level audiologist. 
The medical records do not indicate that you need to have the hearing test with the requested provider. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a tertiary level referral for an audiology evaluation and testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on September 4, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because 
the first scan did not have a copayment. 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 $150 
copayment for CT scans.  
 
You have been asked to pay a $150 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a CT scan provided on September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on July 16, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. 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. The Plan says that 
the referring provider is also out-of-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 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 lab work provided on July 16, 2020 by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1851). 
 
You asked the Plan to pre-approve the brace. You say that the brace is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a knee brace is only covered when there is recent 
injury, surgery, or documented instability of the knee. 
 
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 brace. Our reviewer says that the 
requested brace is not medically necessary. Our physician reviewer found the reviewed records indicate the 
enrollee has osteoarthritis of the knee and he has been receiving knee injections. The records do not 
demonstrate recent injury or surgery or that instability of the knee is found on physical exam. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a knee brace (L1851).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine you received on August 13, 2020. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on August 13, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76770 provided on July 21, 
2020. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 76770 is ultrasound, retroperitoneal (e.g., renal, aorta, 
nodes), real time with image documentation; complete. 
 
We find that CPT code 76770 is not supported in the medical record. Specifically, this claim is an exact 
duplicate to services provided on claim 820202061048615 billed by the same provider for the same date of 
service. Based on this information, we decided that Medicare rules for coverage of the ultrasound services have 
not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services coded 76770 
provided on July 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
13, 2020 to May 18, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the claim was billed with an invalid type ofbill 
for a non-participating Home Health provider. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim has 
been submitted with an invalid type of bill code and is missing the required Q code. Therefore, we decided that 
the Plan does not have to pay for the home health services provided to the enrollee from May 13, 2020 to May 
18, 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
infection of an artificial knee joint. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. 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. 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.