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

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation provided on 
August 22, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. You say that the patient could not 
be transported via other means. The Plan denied your request. The Plan says non-emergent ambulance transport 
to the patient's home was not medically necessary. 
 
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 non-emergency ambulance 
transportation. Our reviewer says that this transportation was not medically necessary. Our physician reviewer 
found the patient is a 69-year-old male with peripheral vascular disease and bilateral above knee amputations 
who presented to the emergency room with acute on chronic phantom pain. He was treated and then discharged 
home. He was transported via ambulance to his home without incident or need for treatment during transport 
and was stable medically. The documentation does not support that other means of transport were 
contraindicated for this patient. The documentation does not support that the patient needed the expertise, 
services and lifesaving and life-sustaining equipment that only a fully equipped ambulance could provide for 
safe transport. The documentation does not support that the ambulance transport 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 non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pay for non-emergency ambulance transportation provided on August 
22, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 that the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that she  
 would meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can receive further 
services 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on May 
30, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you have financial 
troubles. 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 $225 
copayment for one-way trip for Medicare-covered ambulance services.  
 
You have been asked to pay a $225 copayment for the ambulance transport. This item/service falls within the 
one-way trip for Medicare-covered ambulance 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 the ambulance transport provided on May 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0858, E1028, 
E1002, E2300). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you need the requested 
power wheelchair and accessories. The Plan denied your request. The Plan says the requested wheelchair and 
accessories are not necessary. You do not meet criteria for approval of these items. You have a fully 
functioning power tilt wheelchair in good working condition. You are independent with standing and walking 
through your home and driving your vehicle. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition has improved with a cane. The records show that you currently have a functioning power tilt 
wheelchair in good working condition. The records also show you ambulate independently in your home and 
drive your own vehicle. This means that Medicare rules for coverage of a PMD have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0858, E1028, 
E1002, E2300).
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. The Plan denied your request. The Plan says admission to the IRF 
was denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate. 
Skilled nursing facility level of care was offered. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing 
safety concerns and potential for functional improvement however, the documentation doesn't support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you 
would require skilled rehabilitation in an IRF, participating in rehabilitation services fifteen hours a week, 
under the supervision of a physician at least three visits weekly to regain or maintain her functional status. You 
can receive further services 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport rendered on July 25, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee presented to the emergency 
department with acute on chronic phantom leg syndrome. He was treated and sent home via ambulance. He 
was medically stable based on the emergency medical staff assessment and didn't require any treatment during 
transport. The documentation does not support that other means of transport (such as stretcher van, wheelchair 
van) were contraindicated for the enrollee. The documentation does not support that the enrollee 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 was medically 
reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the non-emergency ambulance transport rendered on July 25, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 that the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that he would  
 meet criteria for admission to an acute inpatient rehabilitation facility. The enrollee can receive further services 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that this treatment is considered safe 
and effective, as supported by its clinical benefits to patients, continued medical professional adoption, and 
strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says the 
requested procedure is unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 a Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested vertiflex device is experimental. There is more research 
needed and there is no evidence of efficacy. 
 
 
 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 14, 2022.
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 enrollee has not completed his acute 
care course and is still requiring high flow oxygen. The Plan denied your request. The Plan says the enrollees 
status is critical. The enrollee is receiving medically necessary acute and/or critical care. The enrollee 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility.  The requested treatments are not medically necessary at the 
LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayment for wound care provided on June 20, 2022, and 
June 27, 2022. 
 
You asked the Plan waive the copayment for wound care. You say that no one said wound care was part of the 
hospital and that the hospital would charge extra. 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 $50 
copayment for each in-network outpatient hospital and observation service. 
 
You have been asked to pay $100 ($50 x 2 = $100) for wound care. This item/service falls within the in-
network outpatient hospital 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 waive the copayment for 
wound care provided on June 20, 2022, and June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99203 and 99214), 
provided on May 5, 2022, and July 11, 2022. 
 
You asked the Plan to waive the copayment for the office visits. You say that there should not be a copay. 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 $15 
specialist copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay a $15 specialist copayment for the office visits. This service falls 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 copayment for the office visit (99203 and 99214), provided on May 5, 2022, and July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a magnetic resonance imagining (MRI) of 
the abdomen provided on July 5, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that this service should have been included 
as part of your screening and you would like the copayment waived. 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 $125 
copayment for other Medicare-covered diagnostic radiology services not including x-rays.  
 
You have been asked to pay a $125 copayment for the MRI. You have been asked to pay a $0 copayment for 
the colonoscopy. According to your explanation of benefits there was no copayment charged for the 
colonoscopy on July 18, 2022. The 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 copayments for a magnetic resonance 
imagining (MRI) of the abdomen provided on July 5, 2022, and a colonoscopy provided on July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoe lifts provided on January 5, 2022, to February 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for shoe lifts. You say that this was medically necessary. The Plan denied your 
request. The Plan says you must receive your care from a network provider. 
 
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 shoe lifts provided on January 5, 2022, to 
February 28, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on June 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing provided on June 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional massage therapy visits. 
 
You asked the Plan to pre-approve additional massage therapy visits. You say that additional massage therapy 
visits are medically necessary. The Plan denied your request. The Plan says additional massage therapy visits 
are not covered according to the Plan's contract. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The Plan 
offers a supplemental benefit for massage therapy services. The Plan covers up to 10 massage therapy visits by 
a licensed massage therapist. The Plan does not provide coverage for additional visits beyond this limit. 
Therefore, we decided that the Plan does not have to pre-approve additional massage therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Dimercaprol injections provided to the enrollee from 
February 25, 2021 to July 8, 2021. 
 
You asked the Plan to pay for the injections. You say that you would like to be directly reimbursed. The Plan 
denied your request. The Plan says direct reimbursement claims must be submitted within 12 months for 
medical services 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the injections was not filed until July 29, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for Dimercaprol injections provided to the enrollee from February 25, 2021 to July 8, 
2021.