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 you would like to appeal a continued stay. The Plan 
denied your request. The Plan says a need is not shown for the requested Acute Inpatient Rehabilitation 
admission. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does 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. Our physician reviewer also found that there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on January 25, 
2022. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that the medical records support the 
service rendered and the claim should be reconsidered for payment. The Plan denied your request. The Plan 
says CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient 
department. 
 
  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) provided 
on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair and accessories. 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit 
at your location. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a long-term care facility (LTCF). 
Therefore, we decided that the Plan does not have to pre-approve a wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.  
 
You asked the Plan to pre-approve this service. You say that continued inpatient psychiatric care is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of continued inpatient psychiatric care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that, based upon review the records 
provided, it was not expected this enrollee would improve in a reasonable period of time for the dates in 
question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. The enrollee was 
compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care beyond the dates in question as she did not have dangerousness to self or others and was compliant with 
her treatment. The health plans denial of continued inpatient psychiatric services is appropriate. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve the patients condition or were for the purpose of a diagnosis beyond the 
date in question. Based upon the review of the records provided, this enrollee does not meet the criteria for 
coverage of continued inpatient psychiatric care for the date of service July 14, 2022 going forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 17, 2022, through January 31, 2022. 
 
You asked the Plan to pay for the SNF services. You say that you would like this claim reprocessed. The Plan 
denied your request. The Plan says Medicare rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) 
services provided from January 17, 2022, through January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reset of your vision benefits. 
 
You asked the Plan to pre-approve a reset of your vision benefits. You say that you never got the first pair of 
glasses because you had the order canceled. The Plan denied your request. The Plan says your plan covers one 
routine eye exam and one set of standard eyewear annually. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the lenses and one pair of eyeglass frames or contact lenses every year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan confirmed the glasses were dispensed 
to you on May 23, 2022, and your routine eyewear benefit has been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of a reset of your vision benefits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a reset of your vision benefits.
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 enrollee is currently waiting as inpatient and 
would like to know what the recommendation is for the next level of care. The Plan denied your request. The 
Plan says the service requested does not meet medical necessity. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does 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. Our physician reviewer also 
found that there is not a reasonable expectation that this patient 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: 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 care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility, at home with home health services or at home with outpatient 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that while the enrollee may benefit from continued physical therapy and occupational 
therapy, her rehabilitation needs can be safely provided in a lower intensity and alternate setting such as 
continuing at 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the testing (81479-59) provided on October 28, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that only one unit of this 
code is supported. 
 
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. The Plan argues that two units of code 81479 were billed and only one unit is 
supported in the records, which was paid. However, the records do not show that two units of code 81479 were 
billed for the date of service in question. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the testing (81479-59) provided on October 
28, 2021.  
 
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 waive the coinsurance for a home ventilator provided on March 24, 
2022. 
 
You asked the Plan to waive the coinsurance for a ventilator. You say that if you had known there would be a 
coinsurance charge for the ventilator, on top of the monthly fee, you would have declined the service. The Plan 
denied your request. The Plan says the coinsurance applied was 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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies. The allowed amount of the claim is 
$1167.80, resulting in a coinsurance amount of $233.56. 
 
You have been asked to pay a 20% coinsurance for a ventilator. A ventilator falls within the Advanced Durable 
Medical Equipment (Listed Below): 20% Coinsurance, Medicare-Covered Ventilator. 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 a home ventilator provided on 
March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopathic services provided on February 18, 2021. 
 
You asked the Plan to pay for naturopathic services. The Plan denied your request. The Plan says naturopathic 
services are excluded from your benefits and are not covered under any condition by the Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for naturopathic services provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation of auditory function for a surgically implanted 
device and the diagnostic analysis of a cochlear implant provided on January 6, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the evaluation of auditory function for a surgically implanted device and the 
diagnostic analysis of a cochlear implant. You say that the services were medically appropriate and necessary 
and should be covered treatments. 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 
evaluation of auditory function for a surgically implanted device and the diagnostic analysis of a cochlear 
implant. We found no exception that would require the Plan to pay for the evaluation of auditory function for a 
surgically implanted device and the diagnostic analysis of a cochlear implant. The records provided for review 
do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not 
have to pay for the evaluation of auditory function for a surgically implanted device and the diagnostic analysis 
of a cochlear implant provided on January 6, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight power scooter. 
 
You asked the Plan to pre-approve the requested scooter. You say that you are not able to transport your 
current power scooter. The Plan denied your request. The Plan says the request is more for convenience. 
 
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 scooter, which serves the same purpose as the requested scooter. It 
appears that the lightweight scooter will make it easier to transport and get to appointments. Although it may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pre-approve a lightweight power scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy with biopsy provided on 
February 24, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy with biopsy. You say that this procedure is an 
upper endoscopy to detect abnormal cells or signs of cancer in the esophagus. You also say that this is a 
completely preventive procedure. The Plan denied your request. The Plan says you were charged 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 $325 
copayment at an ambulatory surgical center.  
 
 
 
 
 
  
You have been asked to pay a $325 copayment for an endoscopy with biopsy. An endoscopy with biopsy 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 an endoscopy with biopsy 
provided on February 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy evaluation (97161) 
provided on February 14, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $40 
copayment for each Medicare-covered physical therapy and language therapy visit.  
 
You have been asked to pay a $40 copayment for the physical therapy visit provided. 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 physical therapy evaluation (97161) provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve zinc paste band. 
 
You asked the Plan to pre-approve zinc paste band. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that zinc paste impregnated bandage is covered for 
the treatment of venous leg ulcers that meet the statutory requirements for a qualifying wound. 
 
We looked at the file and Medicare rules. Review of the file does not support that you are being treated for 
venous leg ulcers or venous insufficiency. Based on this information, we decided that Medicare rules for 
coverage of zinc paste band have not been met. Therefore, we decided that the Plan does not have to pre-
approve zinc paste band.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth service provided on March 22, 2022, by an 
out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for the telehealth service. You say that due to the ongoing crisis, you had less staff 
and unable to obtain authorization.  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 
telehealth service. We found no exception that would require the Plan to pay for the telehealth service. The 
records provided for review do not show that telehealth service was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for the telehealth service provided on March 22, 2022, by an out-of-network 
(OON) provider.