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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy care. 
 
You asked the Plan to pre-approve home health care. You say that the enrollee continues to need home physical 
therapy to return to normal activities of daily living. The Plan denied your request. The Plan says the denial of 
authorization for additional home health physical therapy is correct. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer 
found the enrollee does not have documented, ongoing home health physical therapy needs. The enrollee is 
functioning at a level appropriate for a lower level of care such as home exercise program or outpatient therapy. 
The enrollee lives in a supervised environment with assistance available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health physical therapy care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee does not have a means of 
transportation, due to their medical conditions, they need to receive dialysis three times a week. The Plan 
denied your request. The Plan says you have exhausted the established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroiliac (SI) joint injections. 
 
You asked the Plan to pre-approve SI joint injections. You say that the enrollee reports improvement in pain 
and function when performing home exercise program and stretches. The Plan denied your request. The Plan 
says that the denial of authorization for this service is correct, because the record provides no evidence that the 
enrollee responded with capacity to perform maneuvers diagnostic of SI joint pain. 
 
The Plan follows Medicare rules. Medicare rules state that therapeutic SI joint injections may be covered if 
certain criteria are met. 
 
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 SI joint injections. Our reviewer says 
that the enrollee meets the Medicare criteria for the requested SI joint injections. Our physician reviewer found 
the enrollee received a previous SI joint injection that provided 75% pain relief. A supplemental letter states 
that the enrollee has increased mobility after the injection. Therefore, this repeat injection is medically 
reasonable and 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 SI joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve sacroiliac (SI) joint 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the observation visit, and the occupational 
therapy provided by an out-of-network facility from January 2, 2022, to January 5, 2022. 
 
You asked the Plan to waive the coinsurance for the observation visit and the occupational therapy. You say 
that you were told by the Plan that out-of-state services would be covered. The Plan denied your request. The 
Plan says you have been asked to pay the correct cost-sharing 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 30% 
coinsurance for each out-of-network outpatient hospital observation visit and 30% coinsurance for out-of-
network outpatient rehabilitation services.  
 
You have been asked to pay $667.65 which is 30% of the allowed amount for the observation visit. The 
allowed amount is $2,225.64. ($2,225.64 x 30% = $667.65). You have also been asked to pay $29.58 which is 
30% of the allowed amount for the occupational therapy. The allowed amount is $98.59. ($98.59 x 30% = 
$29.58). The observation visit falls within the Outpatient Hospital Observation benefit category. The 
occupational therapy falls within the Outpatient Rehabilitation Services benefit category. The record shows 
you were billed by an out-of-network facility. 
 
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 coinsurance for the observation visit, and the occupational therapy 
provided by an out-of-network facility from January 2, 2022, to January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 testing kit provided on December 
31, 2021. 
 
You asked the Plan to pay for the at-home COVID-19 testing kit. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. CMS says that Plans and insurers are required to cover at-home over the 
counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home COVID-19 testing kit have not been met. Specifically, the at-home COVID-19 testing 
kit was purchased before the date of January 15, 2022. Therefore, we decided that the Plan does not have to pay 
for the at-home COVID-19 testing kit provided on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on September 4, 2021. 
 
  You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). You 
say that the medical records support the claim as originally billed and no coding changes are required. You say 
that the level of service assigned is supported and considered medically necessary. The Plan denied your 
request. The Plan says CPT code 99285 has been overturned and CPT code 99053 remains denied as bundled 
services are not eligible for separate reimbursement. 
 
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 find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on September 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 27, 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 these items/services. 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 January 27, 2022, by an out-of-network (OON) 
provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on December 23, 2021. 
 
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 the enrollee was alert and oriented and ambulated to the stretcher. The 
Plan also says that this does not meet criteria for ambulance transfer. 
 
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 the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not support that other means of transport (such as stretcher van, wheelchair van) were 
contraindicated for the enrollee. The documentation does not support that the enrollee needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe 
transport. Therefore, the reviewer also found that the ambulance services were not medically reasonable or 
necessary on the date of service in this case. 
 
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 for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for carpal tunnel surgery (64721) provided on November 11, 
2021. 
 
You asked the Plan to pay for carpal tunnel surgery (64721). You say that the CPT codes billed allow payment 
to the surgical assistant who rendered the service due to the medical necessity of the service. You say that the 
surgical assistant should receive compensation for ensuring the safety of the member and the claim should be 
processed for payment. The Plan denied your request. The Plan says assistant at surgery may not be paid for 
this code. 
 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 64721. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for carpal 
tunnel surgery (64721) have not been met. Therefore, we decided that the Plan does not have to pay for carpal 
tunnel surgery (64721) provided on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician or other qualified health care professional 
services for outpatient cardiac rehabilitation (93798) rendered by the out-of-network (OON) provider on 
October 25, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the physician or other qualified health care professional services for outpatient cardiac 
rehabilitation (93798) rendered by the out-of-network (OON) provider on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitamin c and albumin infusions, acupuncture, and 
oxygen therapy, provided on October 14, 2021, through October 26, 2021. 
 
You asked the Plan to pay for the vitamin c and albumin infusions, acupuncture, and oxygen therapy. You say 
that the services should be covered. The Plan denied your request. The Plan says these services were not urgent 
and were pre-planned. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved 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 the vitamin c and albumin infusions, acupuncture, and oxygen therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for the vitamin c and albumin infusions, 
acupuncture, and oxygen therapy, provided on October 14, 2021, through October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the nuclear medicine test and Part B drugs 
provided by a network facility from September 21, 2021, to September 22, 2021. 
 
You asked the Plan to waive the cost sharing for the nuclear medicine test and the Part B drugs. You say that 
based on your coverage, these services should have been covered.  The Plan denied your request. The Plan says 
you have been asked to pay the correct cost-sharing 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 in-network Medicare-covered radiological diagnostic services, not including x-rays and 20% 
coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer.  
 
You have been asked to pay $756.48 for the nuclear medicine test and the Part B drugs. The nuclear medicine 
test falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
Part B drugs falls within the Medicare Part B Prescription Drugs benefit category. See chart below. 
 
Date of Service Service Allowed Amount Copayment/ 
Coinsurance 
Member Liability 
September 21, 2021 Part B drug $1,841.18 20% $368.24 
September 22, 2021 Nuclear medicine 
test 
$1,291.29 $20 $20 
September 22, 2021 Part B drug $1,841.18 20% $368.24 
Total    $756.48 
 
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 sharing for the nuclear medicine test and Part B drugs provided by a 
network facility from September 21, 2021, to September 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the therapeutic exercises (97110), the 
physical therapy evaluations (97161), and the extracorporeal shock wave involving the musculoskeletal system 
(0101T) rendered by the out-of-network (OON) provider from March 23, 2021, through May 3, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. Additionally, the services were not medically necessary.  
 
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 issue reimbursement from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the therapeutic exercises (97110), the physical 
therapy evaluations (97161), and the extracorporeal shock wave involving the musculoskeletal system (0101T) 
rendered by the out-of-network (OON) provider from March 23, 2021, through May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on December 6, 2021. 
 
You asked the Plan to pay for subsequent hospital care. You say that the Plan advised you to go to the 
emergency room for suicidal ideation. The Plan denied your request. The Plan says the service code that was 
provider was provided out-of-state and was classified as a plastic surgery hospital visit. The Plan also says that 
the member is unclear as to the details of the visit, and despite multiple requests, no medical records have been 
returned.  
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. You can see this in the Medicare Program Integrity Manual Chapter 3, Section 3.3.2.1. 
 
The 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. You can find 
this rule at 42 Code of Federal Regulations (CFR), Section 424.5.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital care have not been met, and without medical records we cannot determine 
whether this visit was urgent/emergent in nature. You can request the medical records, and then when the Plan 
gets them, they can reconsider payment. Therefore, we decided that the Plan does not have to pay for 
subsequent hospital care provided on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection procedure. 
 
You asked the Plan to pre-approve injection procedure. You say that you need this injection because you 
already had physical therapy that did not work. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because no medical records were submitted by your treating provider to 
support this request. 
 
The Plan must follow Medicare rules. Medicare rules say that to consider coverage for any service, the 
information submitted by the provider must corroborate the documentation in the medical record and confirm 
that coverage criteria have been met. 
 
We looked at the file and Medicare rules. No medical records were submitted by your treating provider. The 
Plan made attempts to obtain medical records, but none were submitted. Without records, we cannot determine 
whether you meet Medicares coverage criteria for the requested injection procedure. Based on this 
information, we decided that Medicare rules for coverage of injection procedure have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an injection procedure.