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

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay was 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 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found at time of admission, level of care for the services were observation. The 
enrollee underwent testing and procedures for future procedure planning. These procedures are not inpatient 
requiring procedures, nor were they medical necessary to be completed during this hospitalization.  Medical 
necessity for inpatient care is not determined. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on February 13, 2020 
and extractions and surgical implant placements provided on March 11, 2020. 
 
You asked the Plan to pay for the limited oral evaluation, extractions and surgical implant placements. You say 
that you fell and several teeth were damaged as a result of the fall. You say that the dental work should be 
classified under medical since the damage was the result of an accident. The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
provided on February 13, 2020 and extractions and surgical implant placements provided on March 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 15, 2019. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that the enrollee's estate is 
insolvent, and you are not responsible for the balance of this debt. The Plan denied your request. The Plan says 
the copayment amount the enrollee has been 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $250 copayment for ground ambulance transportation.  
 
The enrollee has been asked to pay $250 copayment for ambulance transport. Ambulance transport falls within 
the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation provided on December 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on March 28, 
2020. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like 
reconsideration because you did not have another way home. The Plan denied your request. The Plan says this 
service was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the non-emergent ambulance services. Our 
reviewer says that ased on the medical records provided there is no documentation that other means of transport 
(such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated. Our 
physician reviewer found the enrollee's medical conditions were stable at time of discharge from the emergency 
room and there was no documentation of a need for ambulance transport back to her 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 non-emergent ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for non-emergent ambulance services provided on March 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a therapeutic phlebotomy (99195) and
pulse oximetry (94760) performed on February 13, 2020.
You asked the Plan to waive the copayment for a therapeutic phlebotomy and pulse oximetry. You say that you
have never before paid a copayment for labs at the providing facility. The Plan denied your request. The Plan
says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for each visit for Medicare-covered outpatient surgery or procedure at a hospital facility.
You have been asked to pay $110.73 for a therapeutic phlebotomy and pulse oximetry. A therapeutic
phlebotomy and pulse oximetry fall within the "Outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to
pay less than the full 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 therapeutic phlebotomy (99195) and pulse oximetry (94760) performed on February 13,
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 is unable to do three hours a day of 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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
be able to perform fifteen hours per week of rehabilitative services and regular physician evaluation. The 
enrollees 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 27, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on May 27, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance transportation provided on February 4, 2020. You asked the Plan to pay for the ambulance transportation. You say that you did not know that prior authorization was required for transportation from the hospital to another location. You say the provider should have known that prior authorization was needed. The Plan denied your request. The Plan says that non-emergency transportation by ambulance is appropriate if it is documented that the member's condition is such that other means of transportation could endanger the person's health and that transportation by ambulance is medically required. Prior authorization is required for Medicare covered non-emergency services. 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 referred for the ambulance transportation by a contract hospital. The file does not show that the Plan provided notice that the ambulance transportation would not be covered prior to the services being provided. Under Medicare rules, this means the ambulance transportation is considered approved by the Plan. Therefore, we decided that the Plan has to pay for ambulance transportation provided on February 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 pay for the services provided on March 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the clinical trial 
number was not billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number 
on claims for items/services provided in clinical trials/studies/registries, or under CED.  
 
We looked at the file and Medicare rules. The services in question were billed without the clinical trial number, 
as required by 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 the services provided 
on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you would like reconsideration 
because the semi-electric bed is medically necessary. The Plan denied your request. The Plan says the 
documentation does not indicate that the member requires frequent and immediate need for a change in body 
position to qualify for a semi-electric hospital bed. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not clearly reveal that the member's condition has 
failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways 
is not feasible. The head of the bed does not need to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. The documentation does not 
support a need for an immediate or frequent change in body position or special attachments that cannot be fixed 
on an ordinary bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
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 review of available records, the patient does not meet Medicare criteria for 
coverage for an IRF admission. The patient is medically stable with Debility after surgery for colon cancer with 
no evidence of complex medical issues that require monitoring by an inpatient Physical Medicine and 
Rehabilitation (PM&R) physician three (3) times per week or need for acute rehab nursing care. While the 
patient may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence 
of need for an intensive therapy program at the patient's current functional level with therapy 3 hours per day 
with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Admission to IRF is 
not medically necessary based on lack of medical complexity and current functional status of walking 200 feet 
with comprehensive geriatric assessment (CGA). The patient's rehab needs can be met at an alternate, low 
intensity level setting such as a skilled nursing facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397)
provided to the enrollee on February 15, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on February 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this device is safe, effective, and medically 
necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this item 
is correct, because this device has deluxe features which exceed the enrollee's needs and it replaces, rather than 
improves, the function of the arm. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this robotic orthosis is not proven to be more beneficial for the treatment of the 
enrollee's medical condition (function of hemiparesis after stroke) than any available standard therapy. The 
requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to 
improve the functioning of a malformed body member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthotic device.
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. The Plan denied your request. The Plan says the enrollee does not 
require a high level of physician supervision in combination with therapy services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute hospital for surgery for a right hip fracture. Your medical problems are 
stable. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 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 does document 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refill kit for an infusion pump (A4220) and injection 
(J0475) provided on January 31, 2020. 
 
You asked the Plan to pay for the refill kit and injection. You say that you would like reconsideration as these 
supplies are medically necessary. The Plan denied your request. The Plan says delivery ticket submitted did not 
include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to 
corroborate the Delivery Ticket submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
submitted does not include a legible proof of delivery for the billed date of service. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the refill kit for an infusion pump (A4220) and injection (J0475) provided on 
January 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the ambulance service on February 28, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you want the portion paid of this bill 
towards your copay. 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 February 28, 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 the ambulance service on February 28, 2020.