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

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay.

You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were advised by the medical center that transferred you to rehab, that it would be covered and not separately charged. The Plan denied your request. The Plan says 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 $310 per day, days 1-7, per admission for in-network covered hospital stays.

You have been asked to pay a $2,170 copayment for the inpatient rehabilitation stay. ($310/day x 7 days = $2,170) The inpatient rehabilitation stay falls within the "Inpatient hospital care" benefit category. The records show that this was a separate inpatient stay. 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 rehabilitation stay.
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 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 in the Medicare rules section. 
 
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 have a past medical history of stroke and 
hypertension and are living at home receiving physical therapy for hip pain and trouble with ambulation. Your 
medical problems are stable. 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 supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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. 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-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 services (CPT 37225) provided on October 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the number of units 
billed exceeds the daily maximum. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 37225 is 1. You billed 2 units of this code, exceeding the MUE. 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 (CPT 37225) provided on October 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) care.

You asked the Plan to pay for the continued SNF care. The Plan denied your request. The Plan says the
enrollee no longer required skilled care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 pay for the continued SNF care. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found that the documentation does not
support that skilled nursing services were required during the period in question. The enrollee was receiving
skilled therapy services, but not on a daily basis. It was not medically reasonable and necessary to provide
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical
matter, the enrollee did not require the necessary services on an inpatient basis, in a skilled nursing facility
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 the continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pay for continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostheses with advance foot. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not reasonable and necessary. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The physician 
medical progress notes do not support that your current prosthetic foot is not functional or broken. The 
requested entire new prosthesis with advanced foot exceeds your medical needs and is not medically necessary. 
Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prostheses with advance foot.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (CPT code 
22869), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has tried two (2) years of 
conservative treatment that has not worked. You state you believe the member is a good candidate for this 
procedure. The Plan denied your request. The Plan says the services are considered experimental and 
investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy of the 
device. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (CPT 
code(s): 22869 and C1821). 
 
You asked the Plan to pre-approve the services. You say that you are in severe pain all the time. You state you 
cannot tolerate any other spinal procedure and medically need to have this procedure to continue with your life. 
The Plan denied your request. The Plan says the services are considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex Superion device placement surgery (CPT code(s): 22869 and C1821).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for procedures on nerves (CPT code 01470) 
provided to the enrollee on July 6, 2020, by a provider not certified by Medicare. 
 
You asked the Plan to pre-approve the anesthesia services. You say that the enrollee has no control over which 
anesthesiologist/CRNA is selected. The Plan denied your request. The Plan says the provider is not a Medicare 
certified provider, and the health plan cannot make payment to a provider who does not accept assignment 
from Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve 
anesthesia for procedures on nerves (CPT code 01470) provided to the enrollee on July 6, 2020, by a provider 
not certified by Medicare.
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 in the Medicare rules section 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 enrollee has stabilized medically and is 
ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. The enrollee is medically compromised and is unable to participate in rehab services. 
The enrollee's family has decided to transition to comfort care. The enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and coinsurance for an 
injection provided by a participating provider on November 4, 2020, to November 16, 2020. 
 
You asked the Plan to waive the copayment for an office visit and coinsurance for an injection. You say that 
you were told that you would not have any charges. The Plan denied your request. The Plan says the correct 
cost sharing amounts have been applied. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a $20 copayment for physician/practitioner services/in-network/specialist 
and a 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay a $20 copayment for an office visit and a 20% coinsurance of the allowed amount 
for an injection. The total allowed amount is $789.50. The total amount you are being asked to pay is $197.90 
($40 ($20 x 2 office visits = $40) + $157.90 ($789.50 x 20% = $157.90) = $197.90). An office visit falls within 
the physician/practitioner services/in-network/specialist benefit category and an injection falls within the 
Medicare Part B prescription drugs 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 
an office visit and coinsurance for an injection provided by a participating provider on November 4, 2020, to 
November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist services provided on September 
29, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you were admitted to the 
hospital. The Plan denied your request. The Plan says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copay for each Medicare-covered specialist visit for physician services.  
 
The records show that at the time the services at issue were provided, you had not been admitted for inpatient 
care. You have been asked to pay a $35 copay for the services provided. The services fall within the physician 
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 copay for the specialist services provided 
on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Isatuximab-IRFC 10mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this regimen is not supported in the guidelines. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Isatuximab is FDA 
approved for the treatment of multiple myeloma (in combination with pomalidomide and dexamethasone) in 
adults who have received 2 or more prior therapies including lenalidomide and a proteasome inhibitor. Data as 
a single agent or in combination with dexamethasone is limited to phase I and II clinical trials and is not yet 
considered a standard of care. The service is not reasonable or 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Isatuximab-IRFC 10mg for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 
30, 2020, through November 3, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you don't make enough money 
to pay this bill. The Plan denied your request. The Plan says 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 $325 
copayment per day for days 1-5 for each Medicare-covered hospital stay. 
 
You have been asked to pay a $1,300 copayment for the inpatient stay. ($325/day x 4 days = $1,300). The 
inpatient stay 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 stay provided from October 30, 2020, through November 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 23, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 23, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 23, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 20, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you were told x-rays were covered and did not 
know they had to be a specific kind of x-ray. The Plan denied your request. The Plan says you are only enrolled 
in the mandatory supplemental dental benefit, which covers intraoral x-rays and panoramic x-rays. The 
bitewing x-rays you received are not covered by Medicare or by the Plan's mandatory supplemental dental 
benefit. The types of x-rays covered by this benefit are clearly stated in the contract. 
 
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 pay for the 
bitewing x-rays (D0274) provided on October 20, 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 in the Medicare rules section. 
 
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 health plan's denial should be upheld. You do not require the intensity of services 
provided at an IRF. Specifically, you are not shown to require, or to be able to currently tolerate, fifteen hours 
per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower 
level of 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit, and wound repair provided 
on August 13, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit, and wound repair provided 
on August 13, 2020.