Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's new memory loss is but hospital 
induced delirium caused by over medication that resulted in the enrollee not able to show the ability to tolerate 
3 hours of therapy a day, not able to stay alert, support herself, or engage in therapy due to the oral 
medications. At this time, the issues are no longer present, and the enrollee can tolerate 3 hours of therapy per 
day. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for acute 
inpatient rehabilitation benefit coverage under Medicare rules, and the new memory loss makes this less likely 
to be able to tolerate 3 hours of therapy a day.  
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you are requesting an additional 56 
miles for trips to and from your pain management appointments. The Plan denied your request. The Plan says 
the benefit limit has been exceeded. 
 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 50 miles per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exhausts the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the additional mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on November 04, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that the services were referred by an in-network 
provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on November 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 02, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that the provider is in-network, and this was 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on December 02, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 23, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you passed 
out at the laundromat, and denied transfer to the hospital. The Plan denied your request. The Plan says this 
claim was correctly denied as a non-covered service. 
 
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 October 23, 2022. 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 the ambulance response and treatment with no 
transport (A0998) provided on October 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amounts for the eye exams (92014) and 
onabotulinumtoxina (J0585) provided on November 3, 2022, and December 14, 2022. 
 
You asked the Plan to waive the cost sharing amounts for the eye exams and onabotulinumtoxina. You say that 
there was a leftover bottle from a different patient, the doctor did not have enough of the injection to give you, 
and the neurologist said you did not receive the correct dose. You also say that you were advised to come back 
30 days later, and when you went back for another injection, there was never enough medication. 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 $30 
copayment for exams to diagnose and treat diseases and conditions of the eye by a specialist, and a 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay $30 copayments for the eye exams, which falls within the Vision Care benefit 
category. You have also been asked to pay a 20% coinsurance for the Onabotulinumtoxina, which falls within 
the Medicare Part B prescription drugs 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 cost sharing 
amounts for the eye exams (92014) and onabotulinumtoxina (J0585) provided on November 3, 2022, and 
December 14, 2022.  
 
Your complaint about the provider not having enough medication for you is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 13, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that by the 
time the emergency response team arrived and checked your vital signs, you had regained your composure and 
felt much better. You also say that it did not make any sense to be transported to the hospital, and you feel the 
Plan should honor payment. The Plan denied your request. The Plan says this service is not covered by 
Medicare or your health 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 January 13, 2023. 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 the ambulance response and treatment with no 
transport (A0998) provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable contact lenses provided on December 5, 2022.  
You asked the Plan to pay for the disposable contact lenses. You say that you have a $250 allowance to use for 
either glasses or contacts. You say your total was $248.33 which is under the $250 allowance. The Plan denied 
your request. The Plan says the benefit has been exhausted. 
 
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 contact lenses once a year. 
 
We looked at the file and the Plan's rules. Specifically, you received contact lenses on May 29, 2022, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the disposable 
contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the disposable 
contact lenses provided on December 5, 2022.
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 medically necessary for the enrollee 
to receive the rehabilitation needed. The Plan denied your request. The Plan says the enrollee can safely receive 
the services needed in another setting such as a skilled nursing facility or home with home health services. 
 
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 does not meet the criteria for admission to an IRF due to their lack of 
medical complexity, rehab nursing needs and high level of function. While the enrollee may benefit from 
physical and occupational therapy, their rehab needs can be provided in a lower intensity and alternate setting 
such 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve to pre-approve transcatheter implantation of wireless 
pulmonary artery pressure sensor (CardioMEMS). 
 
You asked the Plan to pre-approve CardioMEMS system. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is not in a clinical trial. 
 
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 CardioMEMS system. Our reviewer 
says that there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found that, at this time, 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve to pre-approve transcatheter implantation of wireless pulmonary artery pressure 
sensor (CardioMEMS).
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 enrollee will be best served with 
LTACH services as they are currently in an intensive care unit level setting. The Plan denied your request. The 
Plan says when the enrollee is ready to leave the hospital, they can safely receive their care in another setting, 
such as a skilled nursing 
facility or at home with home health services. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions, alveoplasties, primary closure of 
sinus perforation, reduction of osseous turberosity and removal of torus mandibularis. 
 
You asked the Plan to pre-approve surgical extractions, alveoplasties, primary closure of sinus perforation, 
reduction of osseous turberosity and removal of torus mandibularis.. You say that this should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve surgical extractions, alveoplasties, primary closure of sinus perforation, reduction of osseous turberosity and 
removal of torus mandibularis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
purchased on January 25, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the item was obtained through a provider not enrolled in Medicare. 
 
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 continuous positive airway pressure 
(CPAP) device purchased on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the leadless pacemaker (33274). 
 
You asked the Plan to pre-approve the leadless pacemaker. You say that the service is medically necessary. The 
Plan denied your request. The Plan says leadless pacemakers are not covered when provided outside of an 
approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are not covered when 
provided outside of an approved clinical study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the leadless pacemaker have not been met. Specifically, there is no indication this enrollee is a part 
of a Medicare approved clinical study. Therefore, we decided that the Plan does not have to pre-approve the 
leadless pacemaker (33274).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 10, 2022 to 
September 8, 2022. You asked the Plan to pay for the home health services. You ask to please review the submitted documents and 
we are hoping you will reprocess the claim and provide a reasonable favor. The Plan denied your request. The 
Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 10, 2022. The NOA was not received by the Plan until October 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on August 10, 2022 to September 8, 2022.
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 October 9, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says our policy covers non-emergency ambulance transportation when it is the only way to safely and 
adequately transport a member if other means of transporting a member are unsafe due to a medical condition. 
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  
 Our physician reviewer found the transportation via ambulance upon discharge from the hospital was not 
medically necessary. The enrollee was not bedbound, as evidenced by the ability to stand and transfer. The 
enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport.  Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's 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 the 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 October 9, 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 LTACH is medically necessary and 
the LTACH is better suited to meet the needs of the enrollee. The Plan denied your request. The Plan says the 
LTACH is not medically necessary, and the enrollee's needs are being met in the current hospital. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are 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.  
 
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 procedure code 99233 billed for date of service February 2, 
2022. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the primary 
diagnosis code is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99233 was billed with primary diagnosis code J12.82, pneumonia due to coronavirus 
disease 2019. There is a code first notation for the billed primary diagnosis code. The billed code is not 
permitted to be used as a first listed or principal diagnosis. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99233 billed for date of service February 2, 2022.