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

 
We decided that the Plan does not have to waive the copayment for radiology provided on April 14, 2022. 
 
You asked the Plan to waive the copayment for radiology. You say that this was not done in a hospital but a 
free-standing facility so you shouldnt have this charge. 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 $87.01 
copayment for Basic radiological services. 
 
You have been asked to pay a $87.01 copayment for radiology. This item/service falls within the Basic 
radiological services 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 radiology provided 
on April 14, 2022.
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 should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the requested LTACH care is not 
considered medically reasonable and necessary in this case. 
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. 
 
 
  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 an office visit and initial preventative exam (G0402, 99213) 
provided on May 5, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and initial preventative exam. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not 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 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 an office visit and initial preventative exam 
(G0402, 99213) provided on May 5, 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 portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee suffers from chronic 
obstructive pulmonary disease (COPD) and pulmonary fibrosis which have progressed overtime and recently 
caused her to be hospitalized. You say that the enrollee required treatment with non-invasive ventilation in the 
hospital. You say that the enrollee is now in need of both high flow oxygen and non-invasive ventilatory 
support at home to manage her gas exchange. The Plan denied your request. The Plan says the providers did 
not submit a compelling rationale that supports use of a home mechanical ventilator to deliver assistance rather 
than a bilevel positive airway pressure (BiPAP) with back up rate and average volume-assured pressure support 
(AVAPS.) The Plan says that there is no documentation to suggest a BiPAP with backup rate and AVAPS was 
utilized and failed. 
 
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 ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has COPD, lung cancer, and interstitial lung disease. There is no 
documentation of chronic carbon dioxide (CO2) retention on an arterial blood gas (ABG) while at baseline. 
Therefore, the criteria for ventilatory assistance at home are not met.  If the enrollee does have chronic CO2 
retention, they may benefit from BiPAP with 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 ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 15, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was billed with a date of service inconsistent with Medicare rules governing laboratory 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected.  
 
The date that the specimen was collected was March 30, 2022. This should have been the billed date of service. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for physician's services provided on  
May 2, 2022, and May 3, 2022. 
 
You asked the Plan to waive the cost share for the physician's 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 $203 
deductible.   
 
You have been asked to pay a $62.82 deductible for the physician's services. 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 cost share for physician's services provided on May 2, 2022, and  May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on January 22, 2022, 
to February 01, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you think that the 
insurance should pay it. You paid a long time and havent used it much. You are on a fix income, and it would 
be a hardship. 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 $360 
copayment per day for days 1-5. You pay $0 copayment per day for additional days. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. $360 x 5 = $1,800. Therefore, results in the total cost sharing amount 
of $1,800. 
 
 
 You have been asked to pay a $360 copayment per day for inpatient hospital stay. 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 stay on January 22, 2022, to February 01, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. The Plan denied your request. 
The Plan says the enrollee's benefit for routine transportation has been exhausted. 
 
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 routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that the Plan has 
provided coverage for 24 one-way routine transportation trips in the 2022 calendar year. 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 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you are at/near your baseline function and do not require physician 
supervision by a rehabilitation physician. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are living at home with atherosclerotic heart 
disease and dementia and have had functional decline over last three months such that you can no longer stand 
on your own. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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 have both Parkinson's and dementia and will 
only get half as much rehab at a SNF as you would at an IRF. The Plan denied your request. The Plan says the 
records do not show the need for the intensity of an ARU or full-time access to a doctor or skilled rehabilitation 
nurse. Needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar medial branch nerve radiofrequency coded as 
64635 and 64636. 
 
You asked the Plan to pre-approve the surgical procedure. You say that at this point lumbar medial branch 
nerve radiofrequency is necessary to directly address the nerve impingement and local irritation. The Plan 
denied your request. The Plan says the request is not medically necessary under Medicare rules. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has chronic low back pain and has tried chiropractic therapy and physical 
therapy. The enrollee has tried NSAIDs (non-steroidal anti-inflammatory drugs) and muscle relaxants for pain. 
The physical exam confirms facet arthropathy. MRI demonstrates multi-level facet arthropathy. There is no 
documentation of diagnostic medial branch blocks having been performed. Therefore, the request is deemed 
not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar medial branch nerve radiofrequency coded as 64635 and 64636.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aortography, abdominal, by serialography, radiological 
supervision and interpretation (procedure code 75625) provided to the enrollee on November 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the service billed. 
 
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 75625 is "Aortography, abdominal, by serialography, 
radiological supervision and interpretation." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure note described no 
flow stenosis of the abdominal aorta but no details concerning the vessel nor its bifurcation. On this level, the 
report is insufficient to document the appropriateness of the use of 75625. In addition, since the vascular 
procedure, CPT 37228 and 37232 x2 was billed and paid, Medicare would consider the aortagram part of that procedure as roadmapping and prohibits unbundling of the angiographic portion of the therapeutic procedure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for aortography, abdominal, by serialography, radiological supervision and interpretation 
(procedure code 75625) provided to the enrollee on November 27, 2021.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says that the member does not have clinical conditions that cannot be 
appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic 
advantage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. All medically necessary care is being 
provided in the current acute care setting. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health Plan. The health Plan has 
approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services (A0432) billed for date of 
service April 27, 2022. 
 You asked the Plan to pay for paramedic intercept. You say that this service was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this service was billed incorrectly, and this 
claim must be resubmitted with another procedure code. 
 
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.  
 
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 (A0432) billed for date of service April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 15, 2021, to November 18, 2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the determination to remove the principal diagnosis A41.4 and secondary diagnosis G93.41 was 
appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 pay for the services. Our reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found that during this hospital stay, the 
documentation does not support the coding of A41.4 (sepsis due to anaerobes) and G93.41 (metabolic 
encephalopathy). The enrollee was admitted for urinary tract infection (UTI). In this case there is insufficient 
documentation to confirm A41.4 (sepsis due to anaerobes) and G9341 (metabolic encephalopathy) during 
hospital admission, and query would be made prior to billing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from November 15, 2021, to November 18, 2021.