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

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on June 7, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you had no option but to call 
the ambulance and you feel like this should be covered. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $265 copayment for ambulance services/in-network.  
 
The enrollee has been asked to pay a $265 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance services/in-network 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 
an ambulance trip provided by a participating provider on June 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a physician visit provided by a participating 
provider on June 12, 2020. 
 
You asked the Plan to waive the deductible for a physician visit. You say that you do not agree with this 
deductible amount. The Plan denied your request. The Plan says the correct deductible has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category, what is 
your plan deductible? The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible for what is your plan deductible. This cost sharing is a contractual obligation that had not been 
met at the time a physician visit was received on June 12, 2020. The total amount you are being asked to pay is 
$117.75. Therefore, we decided that the Plan does not have to waive the deductible for a physician visit 
provided by a participating provider on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on March 26, 2020.You asked the Plan to pay forthe CGP testing. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on March 26, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs additional care. 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 enrollee was admitted to the hospital on 
November 14, 2020, with left-sided numbness after a stroke. She has some persistent left sided balance 
difficulty and is working with physical and occupational therapy. She is walking 150 feet with contact guard 
assistance with no device and is contact guard assist for transfers and activities of daily living. She is reported 
to be medically stable for discharge. The complexity of her nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She does 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0650) provided April 9, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the orthosis is medically necessary. The Plan denied 
your request. The Plan says the enrollee has previously received the same item from a different provider. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee had received the same orthosis on August 24, 2018. No documentation was 
provided to show that the existing orthosis was damaged beyond repair or otherwise unable to be used. 
Therefore, we decided that the Plan does not have to pay for an orthosis (L0650) provided April 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 74248) provided on June 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an add-on code. 
 
The Plan must follow Medicare rules. Medicare rules say that add-on codes can only be reported in addition to 
a primary procedure. CPT 74248 is an add-on code. In this case, CPT 74248 was not reported with an 
appropriate primary procedure code. Therefore, we decided that the Plan does not have to pay for the services 
(CPT 74248) provided on June 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. The Plan denied your request. The 
Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the unique skills of a professional therapist are 
not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nuclear stress test provided on 
February 4, 2020, at an out-of-network facility. 
 
You asked the Plan to waive the coinsurance for the nuclear stress test. You say that before this test, you 
confirmed with the cardiologist's receptionist that this service would be covered in-network. The Plan denied 
your request. The Plan says they reached out to this cardiologist and their office said they did not provide you 
with incorrect information.  The Plan says that this coinsurance was charged correctly because the provider is 
out-of-network and they have been for over four years. 
 
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 enrollee's contract with the Plan clearly says that enrollees 
must pay 40% coinsurance for radiological diagnostic services performed at an out-of-network physician's 
office or free-standing facility.  
 
The enrollee has been asked to pay 40% coinsurance for the nuclear stress test. The nuclear stress test falls 
within the radiological diagnostic services benefit category and the provider was out-of-network at the time of 
the services. 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 coinsurance for the nuclear stress test provided 
on February 4, 2020, at an out-of-network facility.
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 enrollee was admitted to the hospital on 
November 13, 2020 with dysarthria, left-sided weakness, and numbness. She is weak and deconditioned with 
poor balance and is working with physical and occupational therapy. She is not walking and is maximum assist 
for transfers and activities of daily living. She is reported to be medically stable for discharge. The complexity 
of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an 
intensive therapy program in an IRF and may not be able to fully participate in such. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental consultation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you need to see an oral surgeon prior to getting dentures. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental consultation.
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. 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 that 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 encephalopathy, acute respiratory failure, sepsis and subarachnoid hemorrhage. 
Medical problems are stable. There are no identified problems that need inpatient medical management. 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. The 
medical record supports a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a urinary tract infection and dizziness. Your medicalproblems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs.You donot require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program.There is not a reasonable expectation that youwill be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 
close medical supervision. 
 
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 shortness of breath and congestive heart failure. Your medical 
problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a 
need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation 
therapy program. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided from March 16, 
2020, through March 31, 2020. 
 
You asked the Plan to waive the copayments for physical therapy. You say that she has not received any 
physical therapy from this provider in March or April. The Plan denied your request. The Plan says the 
copayments 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $35 copayment for each Medicare-covered therapy visit from an in-network provider. 
 
The enrollee has been asked to pay a $35 copayment for each physical therapy visit. The total amount you owe 
is $175 ($35/visit x 5 visits = $175). Physical therapy falls within the "Outpatient rehabilitation services" 
benefit category. The records show that physical therapy was provided. 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 copayments for physical therapy provided from March 16, 2020, through March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on July 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that you only exceeded the $1,500 limit because 
nothing was paid for the crowns that you received. You say that the plan would not pay anything for the 
implant procedure. You say that an exception should be made to cover the most basic dental care. The Plan 
denied your request. The Plan says there is a $1,500 combined allowance for dental services. The Plan says that 
the allowance has been exhausted prior to this date of service. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
the maximum allowance for dental services has been exhausted. The record shows that the Plan paid $380 for 
services that you received on January 8, 2020 and $1,120 for services that you received on March 18, 2020, 
thus exhausting the maximum allowance. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for repairs and supplies for your wheelchair 
you received. 
 
You asked the Plan to waive the coinsurance for the repairs and wheelchair supplies. You say that you were 
told there would be no copay for this service. The Plan denied your request. The Plan says you were charged 
this coinsurance 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the repairs and wheelchair supplies. The repairs and 
wheelchair supplies fall within the durable medical equipment and related 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 coinsurance for repairs and supplies for your wheelchair you received.
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 can safely receive the services needed in other settings. 
 
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 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture. The enrollee's medical problems are stable. There are no identified problems that need inpatient 
medical management. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 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.