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 patient will need IRF care in order to return 
home. He will be on an amiodarone drip but needs rehab before he can go home safely. The Plan denied your 
request. The Plan says the patient's needs can be met in the current hospital setting because they have not 
completed the full course of hospital treatment. 
 
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 currently to be able to tolerate fifteen hours per week of rehabilitative services with 
regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on December 8, 
2021. 
 
You asked the Plan to waive the copayment for an eye exam. You say that you reached your out-of-pocket 
maximum so this should be covered. The Plan denied your request. At the time the claim was received your 
out-of-pocket maximum had not been met. The Plan says the copayment applied is correct. 
 
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 $15 
copayment for each Medicare covered eye exam.  
 
You have been asked to pay $15 copayment for an eye exam. Eye exams fall within the Vision 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 an eye exam provided on December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on May 2, 2022, and 
May 9, 2022. 
 
You asked the Plan to waive the copayment for eye surgery. You say that you shouldn't be charged this much. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $275 
copayment per surgery at an ambulatory surgical center.  
 
You have been asked to pay a total of $518.58 ($259.29 per visit) which is less than the standard $275 
copayment for eye surgery. Eye surgery 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 eye surgery provided on May 2, 2022, and May 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like additional trips to be 
approved for coverage. The Plan denied your request. The Plan says you have already used up all of your trips 
for this benefit year. 
 
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 12 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 transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator. 
 
You asked the Plan to pre-approve a portable home ventilator. You say that a portable home ventilator is 
medically necessary because the patient has chronic respiratory failure and BiPAP would be ineffective as the 
patient requires a volume-targeted mode. The Plan denied your request. The Plan says a BiPAP with AVAPS 
would meet the patient's needs. 
 
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 portable home ventilator. Our 
reviewer says that a portable home ventilator is not medically necessary for this patient. Our physician reviewer 
found this patient has chronic obstructive pulmonary disease and interstitial lung disease.  There is no 
documentation of chronic CO2 retention on an arterial blood gas done while stable as an outpatient.  There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  If the patient does have chronic CO2 
retention, he may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep.  
 
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 portable home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued chiropractic treatment. 
 
You asked the Plan to pre-approve chiropractic treatment. You say that with the chiropractic treatments you 
have been able to maintain a normal life that includes walking daily, doing your own shopping and living with 
very little pain. The Plan denied your request. The Plan says continued chiropractic treatment is not medically 
necessary and is considered maintenance at this point. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 continued chiropractic treatment. Our 
reviewer says that the elements of the coverage criteria have not been satisfied and the requested service is not 
recommended. Our physician reviewer found that the record provided describes maintenance care and when 
further clinical improvement cannot be reasonably expected from ongoing care, the care is considered 
maintenance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued chiropractic treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) services provided on 
December 10, 2021. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that the attached medical records 
should be reviewed. The Plan denied your request. The Plan says Medicare rule for payment of this claim has 
not been met.  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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) services 
provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmology imaging provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for ophthalmology imaging. You say that this should be a $0 
copayment for advanced imaging in a providers office. The Plan denied your request. The Plan says this was 
not coded as advanced imaging.  The Plan says the copayment applied is correct. 
 
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 $125 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service except for the 
following.  
 
 
 
 You have been asked to pay $55.29 which is less than the standard $125 copayment for ophthalmology 
imaging. Ophthalmology imaging 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 ophthalmology imaging 
provided on February 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator. 
 
You asked the Plan to pre-approve a portable home ventilator. You say that you need this item is order to be 
discharged. The Plan denied your request. The Plan says a BiPAP device with AVAPS would meet your needs. 
 
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 portable home ventilator. Our 
reviewer says that a home ventilator is not medically necessary. Our physician reviewer found you have 
chronic obstructive pulmonary disease, obstructive sleep apnea, and  COPD, OSA, and heart failure with 
preserved ejection fraction (HFpEF).  An arterial blood gas at the time of hospitalization for exacerbation of 
HFpEF showed a partial pressure of carbon dioxide of 65 with a normal pH, suggesting chronic CO2 
retention.  You had been discharged with a home ventilator previously, but were unable to use it; it is unclear 
whether you did not tolerate the interface or the device became inoperative.  You may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator when used as 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 portable home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard, power wheelchair, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (K0822). 
 
You asked the Plan to pre-approve a group 2 standard, power wheelchair. You say that the requested 
wheelchair is medically necessary. The Plan denied your request. The Plan says the record sent by your 
provider indicates you had approval of the power wheelchair request, and confirmation of the power 
wheelchair delivery on February 24, 2022. Payment is made for only one wheelchair at a time. Backup chairs 
are denied as not reasonable and necessary. 
 
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 power wheelchair. a power wheelchair serves the same purpose as a group 2 
standard, power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a group 2 
standard, power wheelchair, sling/solid seat/back, patient weight capacity up to and including 300 pounds 
(K0822).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the prophylaxis of retinal detachment 
(67145) provided on January 31, 2022. 
 
You asked the Plan to waive the copayment for the prophylaxis of retinal detachment. You say that you are on 
a fixed income with Social Security, and would like the Plan's decision to be reversed. The Plan denied your 
request. The Plan says the copayment amount you are being charged is correct. 
 
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 in-network Vision care.  
 
 
 You have been asked to pay a $30 copayment for the prophylaxis of retinal detachment. The prophylaxis of 
retinal detachment falls within the in-network Vision 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 prophylaxis of retinal detachment (67145) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like additional trips to be 
approved for coverage. The Plan denied your request. The Plan says you have exhausted almost all of the 
available trips allowed. The Plan also says that this benefit does not cover more than 30 one-way trips per plan 
year. 
 
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 up to 30 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 will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI joint injection. You say that this could help you maintain functionality. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
records do not show any tenderness in the SI joints, positive results of at least 3 provocative tests of the joint, or 
that alternate contributing diagnoses are absent. 
 
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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation on physical examination of 3 or more positive test results 
of SI joint dysfunction. The clinical value and effectiveness of an SI joint injection in the absence of tenderness 
and negative testing results have not been demonstrated in the peer-reviewed literature. 
 
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 injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on March 
20, 2022, to March 28, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you are on a fixed income 
and cannot afford the payment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $320 
copayment per day for days 1 through 5.  
 
You have been asked to pay $1,600 ($320 x 5 days) copayment for inpatient hospital stay. Inpatient hospital 
stay 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 stay provided on March 20, 2022, to March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this is the appropriate treatment option available to 
the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the 
gold standard of lumbar decompression. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Food & Drug Administration (FDA) states that Vertiflex is contraindicated if a 
decompression procedure at the index level has been performed. The enrollee has had a percutaneous image-
guided lumbar decompression (PILD, called the MILD procedure) at the requested treatment level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 18, 2022, to January 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you never asked for a 
private room you were given one due to COVID-19 guidelines so you should only be charged $395. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
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 $395 
copayment each day for days 1 through 5.  
 
 
 
 You have been asked to pay $1,975 ($395 x 5 days) copayment for inpatient hospital care. Inpatient hospital 
care 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 from January 18, 2022, to January 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided from December 1, 
2021, through December 17, 2021. 
 
You asked the Plan to pay for paramedic intercept services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services at issue are not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided from December 1, 2021, through December 17, 2021.