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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to walk and need assistance learning 
how to do that. You also say you have Alzheimer's disease which impacts your memory and makes your 
recovery more difficult as you must relearn what the doctor's teach you each time. The Plan denied your 
request. The Plan says that the admission to a SNF is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require skilled nursing or skilled therapy services. You do not require 
the necessary services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 25, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told there 
was no copayment for these services. 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 $300 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract also clearly says that you must 
pay a $0 copayment after day 5.  
 
You have been asked to pay a $300 copayment per day for days 1-3 the inpatient hospital stay. You have been 
asked to pay a total of $900 ($300 copayment per day x 3 days = $900). You have not been charged for the day 
you were discharged. This item/service falls within the inpatient hospital care 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 inpatient hospital stay provided from February 25, 2022, to 
February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that evidence clearly supports the use of 
the Intracept procedure as the primary treatment for chronic low back pain that is identified by Modic changes. 
You say that the procedure was developed due to a treatment gap for those patients who failed to see 
improvement in their chronic low back pain with today's available treatments before considering more invasive 
procedures such as fusion or disc replacement. You say that the Intracept procedure's safety profile was lauded 
by the Food and Drug Administration. The Plan denied your request. The Plan says medical studies have not 
proven that the requested procedure is helpful for the treatment of the enrollee's health problem. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 
10, 2022, to August 12, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $300 
copayment for inpatient hospital care. 
 
You have been asked to pay a $300 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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 inpatient 
hospital care provided on August 10, 2022, to August 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress test. 
 
You asked the Plan to pre-approve a stress test. You say that the medical records provided support the need for 
the requested stress test. The Plan denied your request. The Plan says the request is not medically necessary 
because the enrollee is able to exercise and does not have hypertrophic cardiomyopathy (HCM.) 
 
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 a stress test. Our reviewer says that the 
requested stress test is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is asymptomatic. There is no documentation that the electrocardiogram (ECG) shows an 
uninterpretable pattern. There is no evidence provided that would support the need for stress echocardiography. 
There is insufficient documentation to support the medical necessity for the requested stress echocardiography 
in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a stress test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a stress test.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each radiology service provided on 
November 01, 2022. 
 
You asked the Plan to waive the copayment for each radiology service. You say that you met your out-of-
pocket maximum and should not owe a copayment for this MRI. 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 $125 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $125 copayment for each radiology service. This item/service falls within the 
outpatient diagnostic test 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 each 
radiology service provided on November 01, 2022.
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. You say that you need IRF services to get better and be able to 
walk without assistance. The Plan denied your request. The Plan says that the admission to an IRF 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 that the documentation does not support necessity for admission to an IRF and the 
complexity of your nursing, rehabilitation, and medical needs (no combined complexity). You do not require an acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. While 
you may benefit from physical therapy and occupational therapy, your rehabilitation needs can be provided in a 
lower intensity and alternate setting such as in a skilled nursing facility or in-home with services. 
 
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 IRF admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for an ultrasound scan of the abdominal aorta (76706) provided on August 
25, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the claim was not billed with the appropriate diagnosis code. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the ultrasound by a contract provider. The file does not show that the plan 
provided notice that the ultrasound would not be covered. Under Medicare rules, this means the ultrasound is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for an ultrasound scan of the 
abdominal aorta (76706) provided on August 25, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enrollment in the Special Supplemental Benefits for 
Critically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve the SSBCI benefit. You say that you meet the criteria for this benefit. The 
Plan denied your request. The Plan says the criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefit have not been met. Specifically, we have confirmed that you do not require 
intensive care management. Therefore, we decided that the Plan does not have to pre-approve enrollment in the 
Special Supplemental Benefits for Critically Ill (SSBCI) benefit.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits.  
  
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 pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT. You say that the enrollee requires skilled care to address physical 
impairments as needed to improve their ability to function. The Plan denied your request. The Plan says the 
request for care is more than needed to treat the enrollee's problems. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PT. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the therapist has established an effective treatment program the enrollee is able 
to continue with a home exercise program. Continued input from a skilled therapist is not medically necessary. 
The plan has approved visits to firm up the home exercise 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 PT have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional physical therapy (PT) visits.
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 want to go to the rehabilitation facility to get 
stronger. The Plan denied your request. The Plan says you do not meet all the required Medicare criteria for 
admission to an IRF. 
 
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 that you are chronically ill and have recurrent falls. You do not have complex or intensive rehabilitation needs. You do not require frequent physiatry oversight. You do not have an acute 
condition. IRF care is medically necessary per the Medicare rules. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee requires the ventilator for the 
treatment of severe COPD and chronic respiratory failure. Alternative devices cannot provide the essential 
multiple ventilation setting that will assist the enrollee in completing his ADLs throughout the day. Battery 
backup is necessary for the enrollee as he will be using it in multiple settings throughout the day. The ventilator 
will be primarily used in IVAPS mode which is specific to this device. The Plan denied your request. The Plan 
says the request for a home mechanical ventilator set in volume targeted pressure support mode that could be 
delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity, 
obesity hypoventilation syndrome, and chronic therapy with opioids. The enrollee was recently hospitalized 
after a fall, with hypoglycemia. An arterial blood gas was consistent with acute hypercarbic respiratory failure.  
Another recent blood gas in the medical record showed a normal PaCO2 of 47. There is no diagnosis of COPD, 
thoracic restrictive disease, or neuromuscular disease. There is no documentation of chronic CO2 retention 
with an ABG done while stable. If this enrollee does have chronic CO2 retention, he may benefit from BiPAP 
during sleep as an outpatient. Medicare does not cover a home ventilator for the treatment of obesity 
hypoventilation syndrome, or when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 services are medically necessary. The 
Plan denied your request. The Plan says the records do not show that is it medically necessary to be in an 
LTACH in place of an acute care 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 there is no evidence that the enrollee requires services that are not currently 
available.  As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent observation care (99226) provided on June 
14, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99226 is subsequent observation care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit.   
We asked our coder 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 service. Our reviewer found the documentation does not 
support the CPT code 99226. The enrollee was medically stable and responded appropriately to treatment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the subsequent observation care (99226) provided on June 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a transthoracic echocardiogram (TTE) 
provided on December 08, 2022. 
 
You asked the Plan to reduce the copayment for a transthoracic echocardiogram (TTE). You say that you think 
that the copayment for this service should be lower. 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 $100 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service. 
 
You have been asked to pay a $100 copayment for a transthoracic echocardiogram (TTE). This item/service 
falls within the diagnostic procedures and tests, including ultrasounds, at all locations of service 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 a transthoracic echocardiogram (TTE) 
provided on December 08, 2022.