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

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, 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 be able tolerate 
fifteen (15) hours per week of rehabilitative services or to require regular physician evaluation. Your care needs 
can be met at a lower level of care (ex. SNF/SAR). 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 15, 2020, to April 17, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not stay two 
days. You say that you left the same day you came in. 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). Your contract with the Plan clearly says that you must pay a $300 
copayment per admission for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per admission for an inpatient hospital stay. It is $300 per 
admission regardless of length of stay; therefore, the correct copayment has been applied. You have not 
reached your $900 maximum for inpatient hospital stays. An inpatient hospital 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 an inpatient hospital stay 
provided by a participating provider on April 15, 2020, to April 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries (CPT Code 93922) provided. 
 
You asked the Plan to waive the cost-share for the services. You say that you do not feel that you owe this bill 
and that it should be covered by the insurance. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received limited bilateral noninvasive physiologic studies of upper or lower 
extremity arteries (CPT Code 93922) provided. The Medicare-allowed amount for the testing 
is less than the set $115 copayment; therefore, you have been asked to pay the lesser amount of $84.14 for the 
services. Your EOC states that enrollees must pay a $115 copayment for each Medicare-covered radiological 
diagnostic service, not including X-rays, performed in a physician?s office or at a free-standing facility (such as 
a radiology center or medical clinic). 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 cost-share for limited bilateral noninvasive 
physiologic studies of upper or lower extremity arteries (CPT Code 93922) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmology services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there are provider?s in-network that can provide this service. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for the eye and medical examination for 
diagnosis and treatment (92004) provided. 
 
You asked the Plan to waive the co payment for the eye and medical examination for diagnosis and treatment. 
You say that you disagree with the co payment as charged because you believe there is no co payment for an 
annual routine eye exam. The Plan denied your request. The Plan says the co payment 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 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
co payment for medical eye exam even if you were only scheduled to receive a preventive service.  
 
You have been asked to pay a $45 co payment for the eye and medical examination for diagnosis and treatment. 
The services provided fall within the medical eye exam 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 co payment for the eye and medical examination for diagnosis and treatment (92004) provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 14, 2020 and 
billed under codes 84443.  
 
You asked the Plan to pay for 84443. You say that this claim should be paid. The Plan denied your request. The 
Plan says code 84443 was ordered for screening purposes and is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The test at issue in this appeal, 84443, was requested solely for screening 
 
 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for lab services provided to the enrollee on May 14, 2020 and billed under codes 84443.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided a 
participating provider on June 28, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went for a simple 
blood test. 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). Your contract with the Plan clearly says that you must pay a $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for an emergency room visit. Since an emergency room visit 
took place, the correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency room visit 
provided a participating provider on June 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye refraction. You say that the service provided was medically necessary. 
The Plan denied your request. The Plan says the routine vision service provided is only covered when provided 
by a routine vision care provider contracted with the plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a routine vision care provider with the Plan. 
 
We looked at the file and the Plan's rules. The case information indicates that the eye refraction was provided 
with an OON provider and not a routine vision care provider with the Plan. Based on this information, we 
decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that 
 
 
the Plan does not have to pay for the eye refraction (92015) provided, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services ordered by your primary physician. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says that this service is not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
Based on the information sent by the plan it appears you were referred for this service by your primary care 
physician who appears to be a contract provider. The file does not show that the Plan provided notice that this 
service would not be covered. You have no control over how this claim would be billed and no control over 
any billing errors. Under Medicare rules, this means this service is considered approved by the Plan. Therefore, 
we decided that the Plan has to pay for lab services ordered by your primary physician on February 20, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 1, 2020. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says the use of 3D-rendering with interpretation and reporting of computed tomography, magnetic 
resonance imaging, or other tomographic modality with image post-processing is not covered separately by 
Medicare as it is contained in the authorized radiologic procedure. Radiologic techniques using 3D-rendering 
will be considered integral to the radiology services and not a separate service. Reimbursement will be based 
on the payment for the primary radiologic imaging service. Per NCCI edits, 76377 is bundled into 70553, 
which was appropriately reimbursed 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim cannot be paid as billed due to 
the bundled relationship with the codes. Medicare rules for coverage of this claim have not been met. 
Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on June 
1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's chronic subluxation cannot be resolved with further chiropractic treatment. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 services are not medically reasonable or necessary. Our physician reviewer found the only treatment 
allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be 
demonstrated by x-ray or by physical examination. There are no submitted imaging studies to reveal evidence 
of a subluxation. The submitted chiropractic chart notes/office visit notes reveal the following: 5/14/20: 
restricted extension range of motion of the lumbar spine, approximately two thirds of normal and myofascial 
pain with taut and tender fibers noted on palpation of the thoracic spine, paraspinals and lumbar spine, 4-6/10; 
5/21/20 and 6/4/20: restricted lumbar extension approximately two thirds of normal; and, 7/2/20: myofascial 
pain with taut and tender fibers on palpation of the thoracic and lumbar spine and paraspinals. These findings 
do not reveal evidence of subluxation per Medicare guidelines. Thus, chiropractic treatment is neither 
supported nor allowed per Medicare guidelines. 
 
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 chiropractic services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service (A0429) provided
April 8, 2020.
You asked the Plan to pay for the ambulance service. You say that the plan has told you that you did not meet
your deductible and this is now your bill. You are not in a position to pay $314.99 and was just barely getting
out $100. The Plan denied your request. The Plan says the claim was processed with the correct $100
copayment applied. $214.99 remained of the $300 deductible. Therefore, the cost share applied correctly per
the Evidence of Coverage.
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 $300 in-network deductible. You must pay this amount before the plan
will pay for their share of covered in-network services. for Ambulance service.
The item or service you asked the Plan to pay for falls within the benefit category Ambulance service. The Plan
has followed Medicare rules by clearly disclosing in the contract that there is $300 in-network deductible. You
must pay this amount before the plan will pay for their share of covered in-network services. This cost sharing
is a contractual obligation that had not been met at the time the ambulance service was received on April 8,
2020. Therefore, we decided that the Plan does not have to pay for the ambulance service
(A0429) provided April 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovascular repair aorto-iliac endograft placement. 
 
You asked the Plan to pre-approve endovascular repair aorto-iliac endograft placement. You say that the 
requested endovascular repair aorto-iliac endograft placement is medically necessary. The Plan denied your 
request. The Plan says the requested endovascular repair aorto-iliac endograft placement is not medically 
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 endovascular repair aorto-iliac 
endograft placement. Our reviewer says that the requested endovascular repair aorto-iliac endograft placement 
is not medically necessary. Our physician reviewer found based on the records the enrollee has an expanding 
infrarenal AAA (4.3cm -->4.9cm over 3mo) that is in need of repair. However, the right common iliac artery is 
described as being only 3cm and not documented to be significantly enlarging.  Therefore the records do not 
support the medical necessity for endovascular repair of the adjacent right common iliac artery at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular repair aorto-iliac endograft placement have not been met. 
Therefore, we decided that the Plan does not have to pre-approve endovascular repair aorto-iliac endograft 
placement.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you are currently in an inpatient 
rehabilitation facility. You received oral medications. You had stable vital signs. You required stand-by 
assistance to contact guard assistance with functional mobility including walking to 70 feet with a rolling 
walker. You required varying assistance with activities of daily living. The documentation does not support that 
you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment. The documentation does not 
 
 
support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you 
do not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider from June 3, 2020, to June 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says prior authorization was 
not obtained. 
 
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 has network providers 
available who can provide the services at issue in this appeal. 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 to the enrollee by an out-of-network provider 
from June 3, 2020, to June 8, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your continued care could be better provided in an outpatient, skilled 
nursing facility or long term care facility setting. 
 
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 weakness and a fall. Your 
medical problems are stable. There are no identified problems that need inpatient medical management. 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. 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 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.