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

 
We decided that the Plan does not have to pay for transport services provided to the enrollee on May 5, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee enrolled in hospice on December 24, 2019 and remained in hospice until 
May 04, 2020. The enrollee then re-enrolled in hospice on May 08, 2020 and passed away on July 01, 2020. 
Per the regulations above, the enrollee's claims would be covered by original Medicare on the date of hospice 
election, until the first day of the following month in which Hospice was revoked which would be August 01, 
2020. The provider needs to submit their request for reimbursement to original Medicare for services rendered 
on May 05, 2020. The claim was denied correctly. It is the provider's responsibility to verify the member's 
coverage, and to know proper billing procedure for Medicare Advantage members on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on May 4, 
2020 and re-enrolled on May 8, 2020. The services in question were provided before the end of that month. 
Therefore, we decided that the Plan does not have to pay for transport services provided to the enrollee on May 
5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 20, 2020. 
 
You asked the Plan to pay for the physician's services. You say that you reside in assisted living and this 
physician periodically comes to your facility to provide services to all residents. You say that you are unable to 
go out to the doctor's office during the COVID-19 
quarantine and you are also disabled. The Plan denied your request. The Plan says you must receive care from 
in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the 
plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan.  
 
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 
physician's services. 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 physician's services provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 6, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
physician's services. 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 physician's services provided on August 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for outpatient mental health services provided from 
July 12, 2020, to July 30, 2020. 
 
You asked the Plan to pay for these services. You say that there is no difference between opt out and out of 
network providers. The Plan denied your request. The Plan says Medicare does not pay for care from opt out 
providers. 
 
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.  
The services at issue were provided by a practitioner who has opted out of the Medicare program or who is not 
considered to be a Medicare eligible provider. You did not follow your Plan contract rules for obtaining care. 
We found not exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for to pay for outpatient mental health services provided from July 12, 2020, to July 
30, 2020.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the MRIs (72146 and 72148). We decided that the Plan does not 
have to pre-approve the CTA (75635).  
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 services.  
 
We decided that the Plan has to pre-approve the MRIs (72146 and 72148).  
 
Our physician reviewer found the review indicates that the requested MRI spinal canal and contents, thoracic; 
without contrast material (72146) and the MRI, spinal canal and contents, lumbar; without contrast material 
(72148) are medically necessary and reasonable. Therefore, we decided that the Plan has to pre-approve the 
MRIs.  
 
 
 
We also decided that the Plan does not have to pre-approve the CTA (75635). 
 
Our physician reviewer found regarding the requested, CTA, abdominal aorta and bilateral iliofemoral lower 
extremity runoff, with contrast material(s), including noncontrast images, if performed, and image 
postprocessing (75635) the submitted information does not document lower extremities arterial pulses, cold 
lower extremities, or evidence chronic leg ulcers. In addition, there is no documentation of abnormal findings 
of ABI or arterial duplex of the abdomen and lower limbs. The review has determined that the requested 
computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with 
contrast material(s), including noncontrast images, if performed, and image postprocessing (75635) is not 
medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the CTA. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from care in an 
LTACH and the clinical information provided supports the medical necessity of this level of care. The Plan 
denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan 
says that the enrollee's care can be provided in the current inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital with hypercapnic 
respiratory failure related to opiate overdose. He was also diagnosed and treated for pneumonia, 
thrombocytopenia, pulmonary emboli. He was able to be extubated and weaned to oxygen. Recent notes show 
the enrollee continuing to improve gradually, on 6L nasal cannula oxygen and heparin. The enrollee appears to 
be requiring additional short-term acute care services to complete treatment and continue weaning off oxygen 
which can be safely performed at the current facility and is likely to take less than 25 days. The enrollee does 
not require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. 
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer 
may be considered when the enrollee's treatment has completed. 
 
 
 
 
 
 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
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 meets the criteria for admission to an 
IRF. The appellant says that IRF care is medically necessary. The Plan denied your request. The Plan says an 
IRF stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of 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 hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spinal surgery. 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). You say that the 
Interspinous Spacer is medically necessary. The Plan denied your request. The Plan says the FDA indication state that the 
VertiFlex Superion Interspinous Spacer is contraindicated in patients with scoliosis. 
 
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 Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22870). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) and 
Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 24, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you had to go to another ENT to 
fix the problem. You say that you want your $25 copayment back. 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 $25 
copayment for provider and professional services at an in-network specialist's office.  
 
You have been asked to pay a $25 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" 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 office visit provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services you had with a cardiovascular 
specialist on May 4, 2020. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you do not believe there is 
cost sharing associated with this service. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan also says that any other coinsurance charged for this date of service, as well as 
cost sharing charged for date of service June 10, 2020, has been waived.  Therefore, the only issue remaining in 
dispute is the $40 office visit copayment for date of service May 4, 2020. 
 
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 $40 
copayment for specialist services.  
 
You have been asked to pay a $40 copayment for the specialist services. 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 services you had with a cardiovascular specialist on May 4, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastroenterology consultation to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the consultation. You say that this doctor is an expert. The Plan denied your 
request. The Plan says the services are available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
gastroenterology consultation to be provided by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve 7 additional home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 7 additional home health skilled nursing 
visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on 
the medical records provided there is no documentation that that skilled nursing services are required to 
effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain your condition and/or prevent deterioration. Based on the records provided 
no acutely unstable conditions are documented and two additional home health skilled nursing visits appear to 
be adequate to meet your needs for medication and dietary management, pain management and home safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 additional home health skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 7 additional home health skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure. 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). 
You say that the Vertiflex procedure would provide significant clinical and quality of life benefits for the 
enrollee. The Plan denied your request. The Plan says there are not enough scientific studies to show that 
inserting a device would be safe and effective. 
 
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 Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22870). 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure.