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

 
We decided that the Plan does not have to pay for the medical services provided by a non-certified provider. 
 
You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says the facility is 
not listed to be an acceptable provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you receive your care from a provider who is eligible to provide services under Original 
Medicare. 
 
The provider in this case is not eligible to provide services under Original Medicare. 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 the medical services provided by a non-certified provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 28, 
2020, to March 1, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's care was medically 
justified as inpatient. The Plan denied your request. The Plan says the enrollee's stay was consistent with 
observational level of care. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was not expected to be treated for at least two midnights duration as the 
enrollee only required colonoscopy and aftercare. Vitals were stable and no active bleeding was noted in the 
emergency department. 
 
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 pay for the acute inpatient hospital care provided from February 28, 2020, to March 1, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99190) provided April 17, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says CPT code 99190 is not eligible for separate payment. 
 
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 code 99190 is not supported in the medical record. Specifically, the enrollee was a hospital 
inpatient at the time services were rendered. Payment for this service is included in the inpatient facility DRG 
payment. Based on this information, we decided that Medicare rules for coverage of the physician services 
have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99190) 
provided April 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services received. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you disagree with the bill 
you received. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 ambulance services.  
 
You have been asked to pay a $250 copayment for the ambulance services. The services provided fall within 
the ambulance 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 the 
ambulance services received.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 

 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided June 20, 2020 to June 24, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that inpatient care was medically necessary.The Plan denied your request. The Plan says that coverage criteria was not met.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 record showed that at the time of inpatient admission the admitting physician reasonablyexpected that the patient's necessary hospital care (including earlier emergency 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 forthe acute inpatient hospital care provided June 20, 2020 to June 24, 2020. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on June 1, 2020. 
 
 
 
You asked the Plan to pay for the test strips (A4253), lancets (A4259), control solution (A4256), and batteries 
(A4235). 
 
You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation 
does not include a valid physician order. 
 
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 physician order or proof of delivery. The Delivery Ticket does not have the 
tracking number on it to corroborate the billed items were delivered. The physician order is over a year old and 
does not list the supplies ordered. 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 diabetic 
supplies provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom breast prosthesis, post mastectomy, molded to 
patient model (CPT Code L8035), breast prosthesis, silicone or equal, without integral adhesive (L8030), breast 
prosthesis, mastectomy form (L8020) and mastectomy bra (L8000). 
 
You asked the Plan to pre-approve the custom fabricated prosthesis. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says the custom fabricated prosthesis is not 
reasonable and necessary. 
 
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 custom fabricated prosthesis have not been met. The custom 
fabricated prosthesis is not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-
approve custom breast prosthesis, post mastectomy, molded to patient model (CPT Code L8035), breast 
prosthesis, silicone or equal, without integral adhesive (L8030), breast prosthesis, mastectomy form (L8020) 
and mastectomy bra (L8000).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health care. 
 
You asked the Plan to pre-approve continued home health care. You say that this is medically necessary. The 
Plan denied your request. The Plan says you do not have skilled needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 continued home health care. Our 
reviewer says that the requested home health services are not medically necessary. Our physician reviewer 
found the medical records provided do not show that you have documented skilled nursing needs. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued home health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued home health care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization care provided on June 5, 2020, through 
June 8, 2020. 
 
You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration because 
the post stabilization care was medically necessary and appropriate for the entire stay. The Plan denied your 
 
 
request. The Plan says the enrollee's medical condition stabilized by 10:01am on June 6, 2020 and subsequent 
care was post stabilization. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that all inpatient care provided after 10:01am on June 6, 2020 to 10:52 pm on June 8, 2020 at the non-contract 
facility was not medically necessary or reasonable.  
 Our physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance 
transport with monitoring to a Plan facility. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post stabilization care provided on June 5, 2020, through June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS device (CPT Codes: C2624 and 33289). 
 
You asked the Plan to pre-approve the device. You say that the enrollee needs this device and procedure due to 
the enrollee's worsening heart failure. The Plan denied your request. The Plan says the notes do not show that 
the enrollee has been enrolled in an approved category B investigational device exemption (IDE) study. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this circumstance, therapy change based on data obtained from a CardioMEMS device 
has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical 
therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not 
met, since the device should still be considered experimental or investigational. 
 
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 CardioMEMS device (CPT Codes: C2624 and 33289).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the member has stabilized medically and is 
ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy 
services on a daily basis. The member is medically stable and can receive further rehab services at a lower level 
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the 
daily skilled services can be provided at a lower level of care than a skilled nursing facility. The member does 
not have any parental medication; complex wound care or new nutrition given via a feeding tube. The member 
is medically stable without any acute exacerbations of chronic medical problems. The member's physical 
function is at or near their baseline and the member can receive services at a lower level of care. Admission to 
a SNF for inpatient skilled rehab services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the Synvisc 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Synvisc. Our reviewer says that 
Synvisc is not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the Synvisc is medically reasonable and necessary for the patient as the medical 
records do not document failure of conservative treatment such as oral medications, physical therapy or 
intraarticular corticosteroid injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood pressure monitor (A4670) June 16, 2020. 
 
You asked the Plan to pay for a blood pressure monitor. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered for our condition. 
 
The Plan must follow Medicare rules. Medicare rules say that codes A4650 - A4927 and E1510 - E1702 may 
be used only for supplies and equipment relating to home dialysis.  
 
We looked at the file and Medicare rules. The CPT code for the blood pressure monitor at issue, A4670, is in 
the range of codes A4650 - A4927 that are only for supplies and equipment relating to home dialysis. The 
record shows this item was not provided in relation to home dialysis. Based on this information, we decided 
that Medicare rules for coverage of a blood pressure monitor have not been met. Therefore, we decided that the 
Plan does not have to pay for a blood pressure monitor (A4670) June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on April 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The claim was billed with an invalid primary diagnosis code. Based 
on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on April 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sixteen (16) additional routine transportation trips for 
the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation to get to the clinic for blood work and doctor visits. The Plan denied your request. The Plan says 
that the enrollee's benefit is exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve sixteen (16) additional routine transportation trips for the 
enrollee.
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 services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 
services are not medically necessary. Our physician reviewer found the submitted records show that you were 
admitted to the hospital on November 15, 2020, with a dislocated shoulder and fractured kneecap after a fall. 
Your medical problems are stable. You have no identified problems that need inpatient medical management. 
There are no complex nursing or rehabilitation needs. You may benefit from further therapy but do not require 
an intensive therapy program 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.