Persius/hicric huggingface dataset:
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 status is unstable and unsafe to transfer to acute inpatient 
rehabilitation. 
 
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 do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to 
continued oxygen desaturations related to COVID infection and pneumonia. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 documentation indicates that you still require acute hospital level of care services 
and is receiving appropriate care at the present acute care hospital. The review has determined that you do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. There are no services available at the LTACH that you require that are not available at the 
health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  forambulance  transportation  services  (A0427 and A0425) provided  on August  4, 2019.You asked the  Plan to pay forthe  ambulance  services.  You say  that you  would  like  reconsideration  because you  agree  that  the services  were not medically  necessary  but would  like  the  member  to be held  liable.The  Plan denied  your  request.  The  Plan  says the  ambulance  services  were not medically  necessary.Medicare  pays  for ambulance  services  only  when  an  emergency  exists  or when  other  means  of transport  would endanger  the patient's  health.  The Plan follows  the same rules. 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  ambulance  services.  Our reviewer  says that  the  ambulance  transportation  was not medically  necessary.  Our physician  reviewer  foundthe  records do not show  any  indication  for  the  ambulance  transportation.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  ambulance  services  have  not been  met.Therefore,  we decided  that  the  Plan does not  have to pay  forambulance  transportation  services  (A0427 and A0425) provided  on August  4, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided. 
 
You asked the Plan to waive the copayment for an MRI. You say that you do not think you received an MRI on 
that date. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $20 
copayment for advanced radiology services.  
 
The medical records show that you received an MRI on March 27, 2020. Therefore, you are responsible to pay 
the $20 copayment.  
 
You have been asked to pay a $20 copayment for an MRI. An MRI falls within the outpatient diagnostic tests 
and therapeutic services and 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 copayment for 
an MRI provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on June 9, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that since the hospital is only 
three minutes from your house, you shouldn't have to pay this copayment. The Plan denied your request. The 
Plan says you were charged this copayment 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 $225 
copayment for each one-way trip for ground ambulance services.  
 
You have been asked to pay a $225 copayment for each one-way trip for the ambulance services. This 
copayment applies regardless of the distance traveled. 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 
ambulance services you received on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea walking cane chair (E1399).You asked the Plan to pre-approvea walking cane chair. You say that the walking cane chair is medically necessary.The Plan denied yourrequest. The Plan says it has already provided items that meet your needs.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 toan enrollee, it is not considered reasonable and necessary.The file shows that the plan has already authorized  a walker with a seat and cane. A walker with a seat and the cane serve the same purpose as a walking cane chair.Therefore, we decided thatthe Plan does not have to pre-approvea walking cane chair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital bed provided on May 31, 2020. 
 
You asked the Plan to pay for the hospital bed. The Plan denied your request. The Plan says you must receive 
your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider 
who is not part of our plans network) will not be covered. If you need medical care that Medicare requires our 
plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-
network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care. In this 
situation, you will pay the same as you would pay if you got the care from a network provider. 
 
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 
hospital bed. We found no exception that would require the Plan to pay for this item. Therefore, we decided 
that the Plan does not have to pay for a hospital bed provided on May 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265) and a non-autogenous connective tissue graft (D4275). 
 
You asked the Plan to pre-approve the biologic materials and non-autogenous connective tissue graft. You say 
that you have a $2,000 allowable for dental services. You also say that these services are for a medical issue. 
The Plan denied your request. The Plan says these services are not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
biologic materials to aid in soft and osseous tissue regeneration (D4265) and a non-autogenous connective 
tissue graft (D4275).
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 May 15, 2020 to May 19, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this copayment. 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 $360 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-
network.  
 
You have been asked to pay less than a $360 copayment per day for days 1-5 for an inpatient hospital stay. The 
total amount you are being asked to pay is $1,170, which is less than your copayment amount of $1,800 ($360 
x 5 days = $1,800). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 May 15, 2020 to May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on May 14, 2020.You asked the Plan to pay forthe dental services. You say that you were advised by the dental office that the services would be covered. You say that now you are stuck with a bill because the services are anot covered.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that services you receive out of network are not covered.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 when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe dental services provided on May 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for endoscopy, wrist, surgical, 
w/release, transverse carpal ligament. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee must use network providers to get their medical care and services. The only exceptions are 
emergencies, urgently needed services when the network is not available, out-of-area dialysis services and 
cases in which the plan authorizes use of out-of-network providers. 
 
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 
physician's services for endoscopy, wrist, surgical, w/release, transverse carpal ligament.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of gastrostomy tube procedure provided on 
February 12, 2019. 
 
You asked the Plan to pay for the gastrostomy tube procedure (49450). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says this service was previously paid and the records do not 
support the service being performed again. 
 
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 49450 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 gastrostomy tube procedure (49450) have 
not been met. Therefore, we decided that the Plan does not have to pay for the replacement of gastrostomy tube 
procedure provided on February 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided on May 20, 2020, by an out-of-network 
provider. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says this is not a network provider and the services were not referred by a network provider or 
rendered in a participating facility. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the DME provided on May 20, 2020, by an out-of-
network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional ST visits. 
 
You asked the Plan to pre-approve the eight (8) additional ST visits. The Plan denied your request. The Plan 
says eight (8) additional speech therapy 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 pre-approve the eight (8) additional ST 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 documentation doesn't support that you 
require additional skilled rehab services to provide treatment that is medically necessary. You do not require 
rehab services to effectively provide treatment, care, and/or services in order to improve your condition, 
perform a maintenance program to maintain your condition and/or prevent deterioration. You are at your 
baseline medical and mental health status. You have not had any recent changes in function or deterioration in 
speech or cognition. The health Plan has approved 2 sessions of skilled speech therapy to establish a home 
exercise program. The additional sessions are 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 the eight (8) additional ST visits. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve eight (8) additional ST visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services (CPT 10061) provided to the enrollee on 
January 11, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 10061 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 10061 is "incision and drainage of abscess; complicated 
or multiple." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do not include documentation of an Incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple being performed on January 11, 2020, therefore this services cannot be verified. 
 
We looked at this coder'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 pay for emergency services (CPT 10061) provided to the enrollee on January 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular surgery services provided on January 23, 2020 
billed with codes 37242, 75630-26, and 75736-26. 
 
You asked the Plan to pay for the vascular surgery services. You say that this was correctly coded and should 
be paid. The Plan denied your request. The Plan says the records do not support the codes billed. 
 
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 asked our coding 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 vascular surgery services. Our reviewer 
says that the documentation does not support the billed codes. Our coding reviewer found the enrollee received 
services which were billed with CPT code Vascular embolization or occlusion, inclusive of all radiological 
supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the 
intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, 
arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms), Common Procedural 
Terminology (CPT) 75630 - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by 
serialography, radiological supervision and interpretation, and, Common Procedural Terminology (CPT) 75736 
- Angiography, pelvic, selective or supraselective, radiological supervision and interpretation. The operative 
report did not include evidence of these services; therefore, these CPT codes cannot be verified. 
 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the vascular surgery services have not been met. Therefore, we decided that the 
Plan does not have to pay for the vascular surgery services provided on January 23, 2020 billed with codes 
37242, 75630-26, and 75736-26.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dilaudid 2 mg for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dilaudid 2 mg for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.