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

 
We decided that the Plan does not have to pay for the emergent ambulance transportation service (A0429, 
A0425) provided on May 29, 2020. 
 
You asked the Plan to pay for this service. You say that the ambulance transportation service was medically 
necessary for the enrollee. The Plan denied your request. The Plan says the ambulance transportation service 
was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 this service. Our reviewer says that the 
ambulance transportation service provided was not medically necessary. Our physician reviewer found that 
based on the medical records provided, there is no documentation that indicates other means of transport (such 
as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. 
The patient had stable vital signs, no temperature was recorded by the ambulance staff; he had no respiratory 
abnormalities on exam or other abnormal physical findings indicating the need for ambulance services. The 
documentation does indicate that the patient needed the expertise, services, and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergent ambulance transportation service (A0429, A0425) provided on May 29, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox (OnabotulinumtoxinA) injections.
You asked the Plan to pre-approve Botox injections. You say that there is no other treatment option for the
enrollee. The Plan denied your request. The Plan says that the enrollee has only trialed and failed 1
antimuscarinic medication. The Plan says that the criteria for approval has not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Botox injections. Our reviewer says
that the requested drug is medically necessary. Our physician reviewer found the requested use of
OnabotulinumtoxinA is FDA-approved for the enrollee's diagnosis. The reviewer found that the current AUA
Guidelines support the use of OnabotulinumtoxinA as a third line treatment of the enrollee's diagnosis. The
reviewer found that the enrollee has been treated with 2 different medications that were not effective.
Therefore, the reviewer found that the provided documentation supports that the requested drug is safe and
effective and otherwise reasonable and necessary for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox injections have been met. Therefore, we decided that the Plan has to preapprove
Botox (OnabotulinumtoxinA) injections.
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 pay for the inpatient hospital care provided from June 9, 2020, to 
June 12, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the inpatient hospital care was unauthorized post-
stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital care. Our reviewer 
says that post-stabilization care services at the non-Plan facility after 10:01 am on June 11, 2020 were not 
medically necessary or reasonable. Our physician reviewer found the review has determined that the treating 
physician document (in the physician notes, on a form, or in an order) that the patient was not stable for 
transfer on any dates of service. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care provided from June 9, 2020, to June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) and the unspecified 
preventive service (D1999) provided on July 8, 2020. 
 
You asked the Plan to pay for the additional periapical x-ray and unspecified preventive service. You say that 
the services you received were urgent and emergent. You say that you had no idea that the dentist would be out 
of network at a different office location. The Plan denied your request. The Plan says 1 periapical x-ray is 
covered per calendar year. The Plan says that the frequency limit for this service has been exceeded. The Plan 
also says that the unspecified preventive service is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit for the additional 
periapical x-ray has been exceeded. The record shows that the Plan paid for the initial periapical x-ray provided 
on this date of service, thus exhausting the benefit. Additionally, the unspecified preventive service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
additional periapical x-ray (D0230) and the unspecified preventive service (D1999) provided on July 8, 2020.
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 needs a LTACH admission. 
The Plan denied your request. The Plan says there is no documentation that the enrollee will benefit from and 
improve with LTACH management. 
 
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 appears to not be appropriate for transfer to LTACH as the enrollee 
doesn't appear to be a candidate for weaning. Current short term acute care needs can take place safely 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 will be considered not medically necessary at 
this time. When treatment has completed and the enrollee is more stable, transfer to a lower level of care may 
be considered. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 17, 2020, 
to March 21, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says by March 16, 2020 the enrollee's evaluation was 
consistent with the ability for self-care at home. 
 
 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 17, 2020, to March 21, 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. The Plan denied your request. The Plan says the enrollee does not 
require frequent rehab physician management, or an interdisciplinary approach for rehab care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee is at standby assist for standing up, contact guard assist for walking using a two-wheeled 
walker, set-up for toilet hygiene, and contact guard assist to wash hands. The enrollee does not require the 
intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation. 
 
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 LTACH is the best option for the enrollee's care. The Plan denied your request. The Plan says there is no clinical advantage of LTACH over acute 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 appears to not be appropriate yet for transfer due to uncontrolled hypertensive urgency. Management for the short term can take place safely 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 will be considered not medically necessary at this time. When treatment has completed and the enrollee is more stable, transfer may be considered. 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: 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 records provided support the need for care in an LTACH. 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 can safely receive the care needed in the current hospital setting. 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 metastatic lesions associated with thyroid cancer. She was treated with thyroidectomy and extensive mediastinal neck dissection, excision left submandibular gland. The course was complicated by bilateral laryngeal nerve paralysis requiring intubation and tracheostomy, delirium, GI bleed, hypotension, acute kidney injury, and infection all of which were treated. Weaning attempts have since failed and the enrollee is receiving tube feeds via NG tube. The enrollee appears to not be appropriate yet for transfer due to insecure feeding source. Additional weaning attempts are needed, which can take place safely at the current facility. 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 will be considered not medically necessary at this time. When treatment has completed and the enrollee is more stable, transfer may be considered. 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 long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for LTACH service is correct. 
 
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 as LTACHs and acute care hospitals are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute 
care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of 
care for any ongoing long-term care needs. 
 
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 a Percutaneous Left Atrial Appendage Closure (LAAC) (33340).
You asked the Plan to pre-approve the LAAC procedure. You say that the LAAC procedure is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that this procedure is only covered when patients are deemed unable to take long-term oral anticoagulation. 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 LAAC procedure. Our reviewer says that the LAAC is not medically necessary in this case. Our physician reviewer found the LAAC (Watchman) device was FDA approved in 2015 based on one trial with lower complication rates compared to original trials. However, longer term follow-up of that trial demonstrated an additional 8 strokes, all in the arm that received the device, calling into question its long term efficacy. A recent meta-analysis also reported a similar all cause stroke rate. The device should still be considered investigational in patients who are tolerating anti-coagulation without bleeding side effects or evidence of recurrent strokes. In this case, there is no documented intolerance to anti-coagulation, therefore Medicare criteria has not been met.
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 LAAC procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Percutaneous Left Atrial Appendage Closure (LAAC) (33340).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation or inpatient care services (including admission 
and discharge services) provided July 7, 2019. 
 
You asked the Plan to pay for observation or inpatient care services. You say that you did not receive proper 
notice of this enrolle's benefit determination, hence the untimely submission of the claim. The Plan denied your 
request. The Plan says the claim was submitted after the timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for observation or inpatient care services was not filed until July 17, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for observation or inpatient care services (including 
admission and discharge services) provided July 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99212) provided on July 22, 2020. 
 
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this is not a covered service according to the 
enrollee's plan of benefits. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient visit (99212) provided on July 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 74018 provided on June 16, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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, we have confirmed that code 74018 
for the x-ray services has a bundled relationship with code 74250 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 74018 provided on 
June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost shares for the Medicare Part B drugs provided on 
January 10, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you cannot afford to pay for 
the services. The Plan denied your request. The Plan says the claim processed correctly according to the plan 
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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the services provided. The services fall 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 cost shares for the 
Medicare Part B drugs provided on January 10, 2020.