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

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that the enrollee 
needs additional trips for medical-related purposes and the enrollee lives in the country and it is difficult to get 
transportation in that area. The Plan denied your request. The Plan says the enrollee has used all of the 
available 24 one-way trips. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the enrollee has used 
all 24 one-way trips this year. Based on this information, we decided that the enrollee has exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
provide coverage for additional routine transportation trips.
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 for the enrollee's 
condition. The Plan denied your request. The Plan says the requested IRF services are not reasonable and 
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 based on the documentation provided, the enrollee does not require the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees 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: 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 are appealing the decision for admission to the 
IRF. The Plan denied your request. The Plan says the medical records submitted do not establish that the 
admission into the IRF is reasonable and 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 the enrollee was admitted for confusion, a fall, and congestive heart failure. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.   
While the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. Medically necessary care can be provided in a different 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 IRF admission and services.
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 are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on the Medicare 
guidelines and the information we have on the enrollee's condition they don't mee the requirements. 
 
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 enrollee was admitted for altered mental status, urinary tract infection, and acute 
renal failure. Medical problems are stable. There are no complex nursing or rehabilitation needs.  While the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the chest provided on  
September 28, 2020. 
 
You asked the Plan to pay for a radiologic examination of the chest. The Plan denied your request. The Plan 
says Medicare denies a claim if it is not received by the Plan within 12 months or 1 calendar year from the date 
when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a radiologic examination of the chest was not filed until May 19, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a radiologic examination of the chest provided on 
September 28, 2020.
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 the enrollee requires an expedited appeal as a delay 
in decision for an acute rehabilitation stay will jeopardize a chance for a full recovery. The Plan denied your 
request. The Plan says admission to the IRF was denied as not meeting acute inpatient rehabilitation criteria, is 
not medically necessary, and a lower level of care might be appropriate. 
 
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 enrollee was admitted to an acute hospital on August 10, 2022 with 
respiratory distress and was found to have multifocal pneumonia, acute on chronic congestive heart failure, and 
respiratory failure. The enrollee was Intubated, treated, and is now left with debility. The enrollee is medically 
stable with decreased function. Comorbid conditions are all stable.  On review of available records, the enrollee 
with history as described does not meet the coverage criteria for an IRF admission. While the enrollee would 
benefit from physical or occupational therapy their needs can be safely provided in an alternate and low 
intensity setting such as in a skilled nursing facility. 
 
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: 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 the enrollee is now impaired with assisted daily 
living function, decreased activity tolerance and endurance, spinal precautions and weakness, and is a fall risk. 
The enrollee would benefit from a 5-7 day stay for acute inpatient rehabilitation for medication management 
and oversight, especially balancing gastrointestinal sensitivities with pain medications to increase mobility and 
monitoring of vital signs and other comorbidities. The Plan denied your request. The Plan says based on 
Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 enrollee was admitted to an acute hospital on August 24, 2022 for elective lumbar 
spinal fusion (L2 to pelvis). Post-op had anemia and was transfused with packed red blood cells. The enrollee 
is medically stable and decreased function. Comorbid conditions are all stable. On review of available records, 
the enrollee with history as described does not meet the coverage criteria for an IRF admission. There are no 
complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. Medically necessary care can be 
provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 19, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on April 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. She has 
not tried and failed the Plan's required drugs, an oral bisphosphonate and zoledronic acid. The records do not 
show that the required drugs would be contraindicated or less effective; therefore, Prolia is not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on March 3, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapeutic exercises. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and the referring 
provider is also out-of-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 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on 
March 3, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasounds provided on June 11, 2021. 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that you cannot afford the copayment. 
The Plan denied your request. The Plan says you have been 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 $100 
copayment per day for ultrasounds.  
 
You have been asked to pay a $100 copayment for the ultrasounds. The ultrasounds fall 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 ultrasounds provided on June 11, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 27, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you suffered a laceration and needed 
to go to the ER as no urgent care centers were open. The Plan denied your request. The Plan says you have 
been 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 emergency room (ER) visit 
provided on April 27, 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 submitted medical records for review to support 
the medical necessity request for admission to the IRF. The Plan denied your request. The Plan says based on 
clinical information provided to us, the enrollee does not have ongoing critical care needs or need for frequent 
multi-specialty consultation, nor does the enrollee have any comorbid conditions requiring a continued acute 
hospital stay. 
 
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 enrollee was admitted for surgical repair of an incarcerated hernia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
Medically necessary care can be provided in a different 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 IRF admission and services.
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 it is necessary for the enrollee to go to inpatient 
rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 enrollee was admitted for congestive heart failure and pneumonia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  While the enrollee has a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on March 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that the enrollee significantly benefited from this 
service. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
  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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient visit provided on March 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on March 14, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the 
ambulance transport was medically necessary and this member could not be transported with any other means 
of transportation. The Plan denied your request. The Plan says prior approval was not obtained for the services 
rendered. 
 
The Plan contract says authorization is required for non-emergency ambulance service. 
 
We looked at the file and the Plans rules. The file shows that prior approval was not obtained. Based on this 
information, we decided that the Plans rules for coverage of ambulance service, basic life support, non-
emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance service, basic life support, non-emergency transport provided on March 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for inpatient hospital care provided on 
February 23, 2021. 
 
You asked the Plan to reduce the copayment for the inpatient care. You say that you feel you should only be 
charged $175 as an outpatient. The Plan denied your request. The Plan says you have been 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 $200 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The records show that you were admitted to the hospital as an inpatient on February 23, 2021. Therefore, you 
have been asked to pay $200 per day for the first day of inpatient care. The inpatient 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 reduce the copayment for inpatient 
hospital care provided on February 23, 2021.