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

 
We decided that the Plan does not have to pre-approve basic life support ambulance transportation. 
 
You asked the Plan to pre-approve basic life support ambulance transportation. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that emergency ambulance services are a covered benefit 
when the services meet the medical necessity requirements. 
 
 
 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 basic life support ambulance 
transportation. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based on the documentation provided, transportation via ambulance is not medically necessary. The enrollee 
does not require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation can be provided by other means (i.e. stretcher van) without 
endangering the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of basic life support ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve basic life support ambulance transportation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for psychotherapy provided on  
November 24, 2021, and does not have to pay for psychotherapy virtual visits (telehealth) provided on 
September 16, 2021, October 7, 2021 and November 30, 2021. 
 
You asked the Plan to waive the coinsurance for psychotherapy and to pay for the virtual visits. The Plan 
denied your request. The Plan says the claims processed 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 40% coinsurance for outpatient mental health care, out-of-network.  
 
You have been asked to pay a 40% coinsurance for psychotherapy. The psychotherapy visits falls within the 
outpatient mental health care, out-of-network 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 coinsurance 
for psychotherapy provided on November 24, 2021. The Plan contract does not cover virtual visits (telehealth). 
Therefore we decided that the Plan does not have to pay for the virtual visits provided on September 16, 2021, 
October 7, 2021 and November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on November 1, 2021, and 
November 2, 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 this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on November 1, 2021, and November 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed (E1399) DME delivery, set up, 
and/or dispensing service (A9901) purchased July 1, 2021. 
 You asked the Plan to pay for the hospital bed and set up. You say that you sent in the papers showing the 
doctor had signed off on the hospital bed since the enrollee is basically confined to it. He cannot walk nor go to 
the bathroom anymore. The bed helps you and the caregiver. The Plan denied your request. The Plan says this 
item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed (E1399) DME delivery, set up, and/or dispensing service (A9901) purchased July 1, 2021.
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 the patient does not require IRF care and she can be managed at a lower 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 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. The patient was 
admitted for respiratory failure, sepsis, and aspiration pneumonia. Her medical problems are stable and she has  
no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program.  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 pre-approve an out-of-network referral to a general surgery specialist 
for the enrollee. 
 
You asked the Plan to pre-approve the referral. You say that the requested provider has experience with the 
complex situation that the enrollee has. The Plan denied your request. The Plan says in order to consider 
approval of an out-of-network provider, this provider must possess unique skills which are required to 
adequately care for the enrollee, and are not available from network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral to a general surgery specialist for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply (K0553) provided October 28, 2021. 
 
You asked the Plan to pay for the CGM supply allowance. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the billed supply code cannot be 
verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or a delivery ticket to indicate the specific supplies or relevant medical records which support medical necessity for the supplies provided in this case. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply (K0553) provided October 28, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99283, J7512) provided on 
January 6, 2021. 
 
You asked the Plan to pay for emergency room services. You say that this was billed correctly. The Plan denied 
your request. The Plan says this was not billed with the enrollee's identification number. 
 
The Plan must follow Medicare rules. Medicare rules say that the unique number assigned by the health plan to 
the insured is required in field 60A of the claim form. 
 
We looked at the file and Medicare rules. This claim was not billed with the unique number assigned by the 
health plan to the insured. Based on this information, we decided that Medicare rules for coverage of 
emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency room services (99283, J7512) provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy service (code 97140) you received from 
a chiropractor on December 14, 2021. 
 
You asked the Plan to pay for the physical therapy service. You say that this office treated you appropriately 
with multiple modalities, so it should be covered. The Plan denied your request. The Plan says physical therapy 
services provided by a chiropractor are not covered.  The Plan has paid for the manual manipulation of the 
spine you received on the same date of service, minus your applicable cost sharing.  However, this therapy 
service is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the physical therapy service (code 97140) you received from a chiropractor on 
December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a therapeutic CGM. You say that you would like this claim reprocessed based on 
the medical documentation. The Plan denied your request. The Plan says the documentation submitted did not 
include a valid proof of delivery or a delivery ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical documentation does not indicate the provider discussed the need for the medical equipment with the enrollee. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
therapeutic continuous glucose monitor (CGM).
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 need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you were admitted for left leg ischemia and had an above the knee amputation 
after failed revascularization procedures. 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 you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In 
conclusion, 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. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, 83789, G0480) provided November 3, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80307, 83789, G0480) provided November 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation provided to the 
enrollee on November 22, 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 criteria for medical necessity are not met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 medically reasonable or necessary. Our physician reviewer found the 
documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining 
equipment that only a fully-equipped ambulance can provide for safe transport. The documentation  does not 
support that the ambulance transport on November 22, 2021 was medically reasonable and necessary for the 
patient. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for non-emergent ambulance transportation provided to the enrollee on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient medical services provided on May 26, 2020. 
 
You asked the Plan to pay for the outpatient medical services. You say that you would like this claim 
reprocessed besides the claim that will not be paid. The Plan denied your request. The Plan says this claim must 
be revised in order for payment due to a submission error. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be reported correctly.  The rules 
say that when an outpatient claim has been submitted with an invalid procedure code, the entire claim will be 
returned to the provider for reprocessing. 
 
We looked at the file and Medicare rules. The claim that has been submitted includes an invalid procedure 
code. This means that this claim will be returned to the provider for corrections. Based on this information, we 
decided that Medicare rules for coverage of the outpatient medical services have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient medical services provided on May 26, 2020.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on August 5, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says your plan covers ambulance transportation only when you are actually transported by 
ambulance. Since you were not transported by this ambulance, the service is not covered under your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 5, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto 24-26 mg tablet. 
 
You asked the Plan to pre-approve Entresto. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto 24-26 mg tablet.  
 
 Benefits for Entresto may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
April 27, 2021. 
 
You asked the Plan to pay for the hospital discharge day management (99239). You say that the medical 
records should be reviewed. The Plan denied your request. The Plan says CPT code 99233 was overturned. The 
Plan also says the medical records submitted did not include documentation of a hospital discharge day 
management of more than 30 minutes; therefore, the service cannot be verified. 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, medical records were not 
submitted that documented a hospital discharge day management service of 30 minutes or more. This means 
that the billed service cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the hospital discharge day management (99239) have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital discharge day management (99239) provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on October 18, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you gave the provider 
your insurance information and thought you would receive a cleaning that would be covered. You also say that 
you feel it is not fair to be charged for an unnecessary exam. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on October 18, 2021.