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

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care provided on March 30, 
2022. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the service was necessary. The 
Plan denied your request. The Plan says they have denied March 30, 2022, as inpatient as the first two (2) days 
were observation care; however, since the enrollee's pain has not been controlled, the Plan has approved 
inpatient stay from March 31, 2022, to April 4, 2022, as the enrollee continues to need pain management care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the review has determined that the inpatient hospital care provided on March 30, 2022, was not 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care provided on March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from April 
5, 2022, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary. 
The Plan denied your request. The Plan says the request is not medically necessary because the records 
received show that your condition has improved, and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our 
physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of March 29, 2022, forward and could have been treated in a lesser 
restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from April 5, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the extremity veins 
provided on November 8, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that your primary doctor referred you to 
have the ultrasound done. You also say you want to know why the insurance did not cover it. 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 $125 
copayment for radiological diagnostic services, including ultrasounds at a free-standing facility.  
 
 The ultrasound is a covered service that has cost sharing. If the allowed amount is less than the cost sharing 
amount found in the EOC, you are responsible for the full allowed amount. You have been asked to pay the 
allowed amount of $102.34, which is less than the $125 copayment for an ultrasound. An ultrasound falls 
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 an ultrasound of the extremity veins provided on November 8, 2021.
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 item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 
 
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 item is not medically necessary. Our physician reviewer found there is no indication that the enrollee 
has chronic CO2 retention, as with an arterial blood gas analysis (ABG) done while the enrollee is stable as an 
outpatient. Bilevel positive airway pressure (Bipap) has not been tried as an outpatient. A home ventilator is not 
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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that foot orthotics should be considered covered durable 
medical equipment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
respiratory failure, chronic obstructive pulmonary disease (COPD), congestive heart failure, and acute kidney 
injury and was discharged home on March 29, 2022, but returned for readmission on the same day because of 
inability to care for yourself at home. 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. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
breasts provided on December 22, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that the staff should be better trained on how 
to insert the contrast dye. You also say you want to be refunded for the $150 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 $150 
copayment for advanced imaging services, including MRIs.  
 
You have been asked to pay a $150 copayment for an MRI. An MRI falls 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 a magnetic resonance imaging (MRI) of the breasts provided on December 22, 2021.  
 Your complaint about the staff needing to be better trained 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology (88305) provided on August 17, 2021. 
 
You asked the Plan to pay for the surgical pathology (88305). You say that the claim does not represent a 
duplicate but an analysis of a biopsy specimen. You say that the claim should be reprocessed as it is now the 
standard of care. The Plan denied your request. The Plan says procedure code 88305 remains denied when 
rendered when the enrollee was an outpatient and has an indicator of 1.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that radiology and other 
diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System 
(OPPS) to the hospital. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the records indicate that the 
member was an outpatient on the billed date of service. Payment for CPT code 88305 is included in the 
payment to the facility and is the responsibility of the facility to any vendor. Based on this information, we 
decided that Medicare rules for coverage of the surgical pathology (88305) have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical pathology (88305) provided on August 17, 2021.
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 current location is not giving you the proper care 
that you need to help you get better. The Plan denied your request. The Plan says the stay is not medically 
necessary based on IRF criteria. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
congestive heart failure. 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. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialty physician office visits provided 
on October 11, 2021, and December 9, 2021. 
 
You asked the Plan to waive the copayments for specialty physician office visits. You say that the providers did 
not fulfill the terms and conditions of their contract with the insurance company to provide professional 
services to you as a patient. You also say that you are requesting a refund of the $90 in copayments that you 
already paid. 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 $45 
copayment for in-network specialty physician medical care in a physician's office.   
The record shows you had specialty physician office visits on October 11, 2021, and December 9, 2021. You 
have been asked to pay a total of $90, which is a $45 copayment for each specialty physician office visit ($45 
copayment + $45 copayment = $90). Specialty physician office visits fall within the Physician/Practitioner 
Services, Including Doctors Office Visits 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 copayments 
for specialty physician office visits provided on October 11, 2021, and December 9, 2021.  
 
Your complaint about the services you received, and facility conditions are 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on August 27, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that these hearing aids were necessary, and you already 
paid out-of-pocket. The Plan denied your request. The Plan says these hearing aids were not purchased through 
the Plan's specified hearing vendor, and therefore these services are denied. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are the specified models/brand and provided by the Plans specified routine 
hearing vendor.  
 
We looked at the file and the Plan's rules. These hearing aids were not purchased through the specified vendor. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) purchased on August 27, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Teeter FitSpine LX9 inversion table (E0941). 
 
You asked the Plan to pre-approve the inversion table. You say that you have serious back problems and this 
item would be beneficial. This will improve and help your condition as you are no longer getting injections in 
your back. The Plan denied your request. The Plan says no clinical documentation was provided indicating why 
the requested device is needed or a standard written order. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records does not contain a valid physician order or relevant medical records which support medical necessity. Based on this information, we decided that Medicare rules 
for coverage of the inversion table have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Teeter FitSpine LX9 inversion table (E0941).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on July 23, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was unrelated to the enrollee's 
hospice diagnosis. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on July 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalography (EEG) (95822) provided on May 6, 
2021. 
 
You asked the Plan to pay for EEG 95822. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the records do not 
support this code. 
 
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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
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 EEG 95822. Our reviewer says that code 95822 does not 
meet criteria for payment. Our reviewer found the procedure report does not document an EEG for recording patient in coma or sleep. This procedure is not supported in the technical report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EEG 95822 have not been met. Therefore, we decided that the Plan does not 
have to pay for electroencephalography (EEG) (95822) provided on May 6, 2021.