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

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 7, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an emergency department visit provided on January 7, 2022.
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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot 
be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a 
therapeutic advantage. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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: 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 an IRF does not meet 
criteria. 
 
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 were admitted for renal failure and dialysis. 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopy procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has not been able to 
achieve sustainable or satisfactory weight loss. The Plan denied your request. The Plan says there are no 
objective measurements of the enrollee's weight. 
 
The Plan follows Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy services are only 
covered under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has morbid obesity. The record provided does not document a recent in person 
evaluation. The record provided does not document an objective weight measurement. The record as provided 
is insufficient to establish the medical necessity of the requested service. The elements of the coverage criteria 
are not satisfied. The requested service is not recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a laparoscopy procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (72131) 
provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says this cost sharing was charged 
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 $250 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $139.32 copayment for the CT scan, which is less than the standard $250. This 
item/service 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 a computed tomography (CT) scan (72131) provided on 
July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the necessary 
services may be obtained in-network. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visits provided on May 30, 
2022, July 4, 2022, and July 11, 2022. 
 
You asked the Plan to reduce the copayment for the urgent care visits. You say that this is the only place you 
can go to see the doctor. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay a $30 copayment for each urgent care visit. This item/service falls within the 
Medicare-covered urgent care facility visit 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 reduce the copayment 
for the urgent care visits provided on May 30, 2022, July 4, 2022, and July 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities, physical therapy, speech therapy, 
occupational therapy and self-care/home management training provided from October 26, 2021, to  
October 29, 2021. 
 
You asked the Plan to pay for therapeutic activities, physical therapy, speech therapy, occupational therapy and 
self-care/home management training. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the members terminal 
condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare 
also covers attending physician services and all care unrelated to the terminal illness until the first day of the 
month following the month in which hospice was revoked or discharged. 
 
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 16, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for therapeutic 
activities, physical therapy, speech therapy, occupational therapy and self-care/home management training 
provided from October 26, 2021, to October 29, 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 IRF admission is medically necessary and more 
appropriate than skilled nursing. The Plan denied your request. The Plan says the patient does not meet IRF 
coverage criteria as the patient can be managed 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. Our 
physician reviewer found the patient does not require the intensity of services provided at an IRF.  Specifically, the patient is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation.  The patients care needs can be met at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the SPRINT Peripheral Nerve 
Stimulation (PNS) system. 
 
You asked the Plan to pre-approve the Sprint PNS system. You say that this is a coverable service and is 
medically necessary. The Plan denied your request. The Plan says current literature does not support the use of 
SPRINT PNS system for this member's chronic pain. Although it is Food and Drug Administration (FDA) 
approved, it is still under review for overall support for use in chronic pain management. 
 
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 the Sprint PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this 61-year-old female was being treated for spondylosis without myelopathy or 
radiculopathy. She presented with back pain that is rated at 7-8/10. The exam revealed a decreased range of 
motion due to pain. However, there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed 
to establish the efficacy of this treatment over standard treatments for low back pain. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested SPRINT PNS system, in this case, is not medically reasonable or 
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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implantation of the SPRINT Peripheral Nerve Stimulation (PNS) system.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
December 1, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says that 
the Plan did not receive a primary carrier's Explanation of Benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
the primary carrier's Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for 
the emergency department visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit provided on December 1, 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 IRF admission is medically necessary for the patient 
to build strength and help with mobility. The Plan denied your request. The Plan says IRF admission is not 
medically necessary as the patient can be managed 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. Our 
physician reviewer found the clinical documentation shows that patient has functional impairments and active comorbidities, but has not tolerated multiple therapy sessions due to medical issues. Therefore, the patient 
would not be expected to tolerate 3 hours of therapy per day or 15 hours of therapy per week in an IRF 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 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 pay for ambulance services provided on December 30, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that because these ambulance services occurred 
on the day of discharge, they are separately payable. The Plan denied your request. The Plan says these 
ambulance services are not separately payable from the inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that generally ambulance services provided as part of 
a Part A-covered hospital stay are bundled into the payment for the hospital.  However, there is an exception 
for ambulance services with a date of service that are the same as an admission or discharge date on an 
inpatient claim.  These ambulance services are separately payable and not subject to the bundling rules.    
 
In this case, you billed with date of service December 30, 2021.  According to claims history and the Common 
Working File (CWF), the patient's date of discharge from the hospital was January 1, 2022, not December 30, 
2022.  As a result, the patient was still considered an inpatient on the date of service in question, and the ambulance services are considered bundled into the Prospective Payment System payment.  
 
We looked at 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 ambulance services provided on December 30, 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF admission is not medically necessary as the patient is unable to 
participate in the level that is required at an IRF. The patient's needs can be met 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. Our 
physician reviewer found the patient does not require the intensity of services provided at an IRF.  Specifically, the patient is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation.  The patients care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eylea. 
 
You asked the Plan to pre-approve eylea. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 eylea. Our reviewer says that the 
enrollee does not meet step therapy requirements. Our physician reviewer found there is no documentation of a 
trial and failure of Avastin or documentation that the required drug would be less effective or have adverse 
effects for the 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 eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tandem T: Slim x2 insulin pump. 
 
You asked the Plan to pre-approve Tandem T: Sim x2 insulin pump. You say that the last time you received 
your insulin pump it was not good quality and not a good connection with Dexcom. You tried the Tandem T: 
slimx2 and it connected well with your Dexcom G-6. The Plan denied your request. The Plan says this request 
is not reasonable and necessary as there is no acceptable documented reason to change brands. 
 
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 to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Medtronic insulin pump and Dexcom continuous glucose monitor. The 
Medtronic insulin pump serves the same purpose as Tandem T: Slim x2 insulin pump. Therefore, we decided 
that the Plan does not have to pre-approve the Tandem T: Slim x2 insulin pump.