Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Covid-19 vaccine. 
 
You asked the Plan to pay for a Covid-19 vaccine. You say that you are requesting reconsideration and 
payment for services as in-network. The Plan denied your request. The Plan says Medicare payment for 
COVID vaccinations administered during calendar years 2020 and 2021 to MA beneficiaries will be made 
through the Medicare Fee for service (FFS) program. 
 
The Plan must follow Medicare rules. Medicare rules say payment for COVID vaccinations administered 
during calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare FFS program.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Covid-19 vaccine have not been met. Specifically, payments for a Covid-19 vaccine will be made 
through the Medicare FFS program and not the MA plan. Therefore, we decided that the Plan does not have to 
pay for a Covid-19 vaccine.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 is improving but still require acute care services before transitioning to a 
lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. 
 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery services provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for surgery services. You say that your copay should be lower. The 
Plan denied your request. The Plan says the copayment was 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 $350 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
  You have been asked to pay $350 for the surgery services. Surgery services fall within the Outpatient Surgery 
and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 
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 outpatient surgery services 
provided on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal, subcutaneous cardiac rhythm monitor (33286), 
and insertion, subcutaneous cardiac rhythm monitor (33285). 
 
You asked the Plan to pre-approve removal, subcutaneous cardiac rhythm monitor, and insertion, subcutaneous 
cardiac rhythm monitor. You say that the requested services are medically necessary. The Plan denied your 
request. The Plan says the services at issue are 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 removal, subcutaneous cardiac rhythm 
monitor, and insertion, subcutaneous cardiac rhythm monitor. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found while the enrollee has a history of atrial fibrillation, there is no documentation provided to suggest a 
history of unexplained syncope, cryptogenic stroke or any other apparent indication for an implantable loop 
recorder (ILR). As such, based on current guidelines and the documentation provided, there is insufficient 
clinical evidence to support the medical appropriateness and necessity of replacing the enrollees old ILR with 
a new ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of removal, subcutaneous cardiac rhythm monitor, and insertion, subcutaneous 
cardiac rhythm monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve 
removal, subcutaneous cardiac rhythm monitor (33286), and insertion, subcutaneous cardiac rhythm monitor 
(33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 21, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this testing is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on December 21, 2021, have been met. In this case, no clinical records have been provided that indicate the 
medical necessity of the ordered testing. Therefore, we decided that the Plan does not have to pay for the 
genetic testing services provided on December 21, 2021.
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 you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says based on Medicare guidelines, the Inpatient 
Rehabilitation Facility (IRF) services you and/or your provider are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found IRF admission is not medically necessary based on lack of medical complexity and 
acute rehab nursing needs. The document does not support the medical necessity for admission to an IRF. 
While the enrollee may benefit from continued PT and OT, his rehab needs can be safely provided in a lower 
intensity and alternate setting such as in a SNF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
14, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you had to be transported by 
ambulance to undergo a heart catheterization and placement of 3 stents. The Plan denied your request. The Plan 
says you have been charged the correct copayment 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 $275 
copayment for each one-way Medicare-covered in and out-of-network ambulance transport.  
 
You have been asked to pay a $275 copayment for ambulance transport. ambulance transport falls within 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transport provided on December 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services coded 71275 and 74177 provided on 
December 19, 2021. 
 
You asked the Plan to pay for the imaging services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this is a duplicate claim to 
services already paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that claims or claim lines that have 
been determined to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services as billed have not been met as these services are duplicates to what has already been paid. Therefore, we decided that the Plan does not have to pay for the imaging services coded 
71275 and 74177 provided on December 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for repair of an upper eyelid provided on 
January 12, 2022. 
 
You asked the Plan to waive the copayment for repair of an upper eyelid. You say that you are requesting 
reconsideration of your responsibility of $325.00. The Plan denied your request. The Plan says you have been 
charged the correct copayment 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 $325 
copayment for in-network surgery service at an ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for repair of an upper eyelid. The repair of an upper eyelid falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 repair of an upper eyelid 
provided on January 12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0429) provided October 12, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for payment for these services. 
 
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 October 12, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
(A0425, A0429) provided October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implantable, insertable, and wearable cardiac device 
evaluations provided on January 24, 2022. 
 
You asked the Plan to pay for implantable, insertable, and wearable cardiac device evaluations. The Plan 
denied your request. The Plan says the Plan does not have a record that your facility requested a benefit 
certification from the Plan prior to rendering the service, which was neither urgent nor emergent in nature. 
 
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 
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 implantable, insertable, and wearable cardiac device evaluations 
provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on February 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99233 is not separately 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 99233 is a column II code to column I code 99232. This claim has 
not been billed with an appropriate modifier to bypass the edit. 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 subsequent hospital 
care rendered on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan 
does not have to pay for the office visit provided on February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 22, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you have Macular Degeneration and have to see 
an eye doctor regularly. You also say that the provider you saw was listed on the Plan's website as a network 
provider. The Plan denied your request. The Plan says the eye refraction service is not a covered benefit since it 
was medical vision check. The Plan also says that eye refractions are only covered by your plan if performed 
by a participating provider and performed as a routine screening. 
 
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 the eye refraction is performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that the eye refraction was performed during a 
medical vision check for Nonexudative age-related macular degeneration, 
Bilateral, early dry stage. 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 on March 22, 2022.
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 ongoing skilled therapy and nursing needs can be provided at a 
lower level of 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 in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture 
after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 5, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that the service was provided during the Coronavirus 
Pandemic. You say the service was medically necessary. The Plan denied your request. The Plan says no prior 
authorization was 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 did not pre-approve the 
psychotherapy. We found no exception that would require the Plan to pay for the psychotherapy. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on May 5, 2021, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary to receive rehabilitation so 
you can return home. The Plan denied your request. The Plan says the enrollee does not need to be seen by a 
rehabilitation doctor 3 times a week, does not need 3 hours of therapy a day or an intensive team for their care. 
The enrollee can safely receive services in other settings like a skilled nursing facility (SNF), home with home 
health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs identified or 
documented. 
 
At the current level of function, the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. An uncomplicated hip 
fracture patient does not need an IRF admission. IRF admission is not medically necessary based on the lack of 
medical complexity and acute rehabilitation nursing needs. Documentation does not support the medical 
necessity for admission to an IRF. 
 
While the enrollee may benefit from continued physical therapy and occupational therapy, his rehabilitation 
needs can be safely provided in a lower intensity and alternate setting such as in a SNF. 
 
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 IRF admission and services.