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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care continues to be medically reasonable and 
necessary. The Plan denied your request. The Plan says SNF care is no longer medically reasonable and 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided you do not have documented skilled 
nursing needs. In addition, you do not have documented skilled therapy needs. You are currently ambulating 
more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are 
not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 
Your care needs, custodial and intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services and physical therapist services (Q5001, 
G0151, 3LC21) provided on April 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services and physical therapist services. You say that the 
services should be covered as you disagree with the denial. The Plan denied your request. The Plan says the 
services denied correctly as they were non-emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services and physical therapist 
services (Q5001, G0151, 3LC21) provided on April 11, 2022 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services provided on February 1, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you felt better when the 
ambulance arrived and they left.  You said that you then had to call the ambulance a second time to be 
transported to the hospital.  You believe that because these two ambulance services were related, this should be 
covered. The Plan denied your request. The Plan says non-transport ambulance services are not covered. 
 
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 February 1, 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 non-transport ambulance 
services provided on February 1, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for emergency transportation provided on February 4, 2022. 
 
You asked the Plan to pay for the emergency transportation. You say that ambulance services should be 
covered by the Plan. The Plan denied your request. The Plan says that this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided no details as to why it denied your claim.  It 
has provided no records, no documents explaining the denial, and no rules upon which its denial was based.  
The burden is on the Plan to show why its denial is appropriate.  Because the Plan failed to supply any of this 
documentation in the case file it submitted to us, we find that the Plan's denial is not supported. Therefore, we 
decided that the Plan has to pay for emergency transportation provided on February 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar artificial disc replacement. 
 
You asked the Plan to pre-approve lumbar artificial disc replacement. You say that the medical records support 
this is necessary for your condition. The Plan denied your request. The Plan says this is not covered for 
enrollees over 60 years of age. 
 
The Plan must follow Medicare rules. Medicare rules say that Lumbar Artificial Disc Replacement (LADR) is 
not reasonable and necessary for the Medicare population over 60 years of age; therefore, LADR is non-
covered for Medicare beneficiaries over 60 years of age.  
 
We looked at the file and Medicare rules. The record shows that you are over 60 years of age. Based on this 
information, we decided that Medicare rules for coverage of lumbar artificial disc replacement have not been 
met. Therefore, we decided that the Plan does not have to pre-approve lumbar artificial disc replacement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for date of service February 17, 2022. 
 
You asked the Plan to pay for code 99291. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says the medical records do not support the billing of 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 
99291 is evaluation and management of the critically ill or critically injured patient, first 30-74 minutes. 
Because this is a time-specific code, the number of minutes spent on this service must be clearly documented in 
the medical record.  The medical records you provided do not document the number of minutes spent providing 
this critical care service. Therefore, we decided that the Plan does not have to pay for code 99291 billed for 
date of service February 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the documentation provided, you do not have documented skilled 
nursing needs. In addition, you do not have documented skilled therapy needs. You are ambulating more than 
100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be 
provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the refraction testing provided on March 28, 2022. 
 
You asked the Plan to pay for the refraction testing. You say that you feel this should be covered. The Plan 
denied your request. The Plan says that this was correctly denied because Medicare does not cover refractions. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans must clearly describe all benefits available 
under the Plan. The contract indicates that Medicare does not cover eye refractions/routine eye exams; 
however, the Plan does.  
 
We looked at the file and Medicare rules. Though this visit may have included evaluation of medical 
conditions, it also included a routine eye exam for prescription of eyeglasses. This is covered under your Plan 
at no charge. We find there is no language that would allow for this to be denied simply because it was done 
along with a medical eye exam. Based on this information, we decided that Medicare rules for coverage of the 
refraction testing have been met. Therefore, we decided that the Plan has to pay for the refraction testing 
provided on March 28, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator. 
 
You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator. You say that this device is 
medically necessary. The Plan denied your request. The Plan says this device is not currently recommended by 
the American Heart Association because there is no data showing a decrease in hospitalizations or a reduction 
in mortality.  There is also no indication that this patient is enrolled in a clinical trial for this device. 
 
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 an Optimizer Smart Implantable Pulse 
Generator. Our reviewer says that an Optimizer Smart Implantable Pulse Generator is not medically necessary. 
Our physician reviewer found an exhaustive review of the current medical literature pertaining to the Optimizer 
Smart Implantable Pulse Generator (a cardiac contractility modulation (CCM) device) system confirms 
multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of 
CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, 
with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. 
While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. At the current time, the CCM system is not medically necessary in this 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 an Optimizer Smart Implantable Pulse Generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction testing provided on May 2, 2022. 
 
You asked the Plan to pay for the refraction testing. You say that you were told by the provider that all would 
be covered except for a $30 copayment. You were not informed in any way that refractive services would not 
be covered. The Plan denied your request. The Plan says you received this refractive testing during a medical 
(Medicare-covered) eye exam. This testing is only covered as part of a routine exam with an EyeMed provider. 
 
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 refraction testing only during routine eye exams with an EyeMed routine vision care 
provider.  
 
We looked at the file and the Plan's rules. You were seen by a non-routine vision provider for a medical 
diagnosis. Your Plan does not cover routine eye exams/refraction provided by a medical eye care provider. 
Based on this information, we decided that the Plan's rules for coverage of the refraction testing have not been met. Therefore, we decided that the Plan does not have to pay for the refraction testing provided on May 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided March 25, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that DRG 812 was correctly billed. The Plan denied 
your request. The Plan says these services are more appropriately represented by DRG 292. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 812. 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 inpatient care. Our reviewer says that the provided records do not support the 
DRG billed. Our physician reviewer found documentation supports that the patient was admitted to an acute 
level of care for continued evaluation and treatment of his diagnosis of anemia. DRG 292 appropriately 
describes the services provided.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient care provided March 25, 2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for emergency ambulance services provided on July 14, 2021. 
 
You asked the Plan to pay for the emergency ambulance services. You say that this was an emergency 
ambulance service that began at your home.  This should not have been denied. The Plan denied your request. 
The Plan says that these services are not covered when performed at a military, Department of Defense, or 
Veteran's Affairs facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole denial rational is that these services were performed 
at a military, Department of Defense, or Veteran's Affairs facility.  However, the Plan provided no proof in the 
case file it submitted to us that these services occurred at one of these facilities.  The claim submitted by the 
ambulance company clearly states that you were picked up at a residence.  The Plan has provided no supporting 
documentation for its denial.  The burden is on the Plan to show that its denial was correct.  By failing to 
provide any documents showing that these services were rendered at a military, Department of Defense, or 
Veteran's Affairs facility, the Plan has not met this burden. Therefore, we decided that the Plan has to pay for 
emergency ambulance services provided on July 14, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for date of service March 14, 2022. 
 
You asked the Plan to pay for code 99291. You did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 99291 is evaluation and management of the critically ill 
or critically injured patient, first 30-74 minutes. Because this is a time-specific code, the number of minutes 
spent on this service must be clearly documented in the medical record.  The medical records you provided do 
not document the number of minutes spent providing this critical care service. Therefore, we decided that the 
Plan does not have to pay for code 99291 billed for date of service March 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 17, 2021. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records showing 
that you have not exceeded the allowable for this service. The Plan denied your request. The Plan says because 
the enrollee was on hospice on the date of service, either hospice or Original Medicare is responsible for this 
bill. 
 
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 medical services provided on November 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care because you are totally disabled 
and are unable to walk. The Plan denied your request. The Plan says SNF services are not medically necessary 
for you. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing needs or skilled therapy needs.  You are 
not shown to have an acute decline in function. Daily skilled services are not shown to be required to establish 
a maintenance program or to prevent deterioration of your 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hip replacement procedure performed on 
December 15, 2021. 
 
You asked the Plan to waive the coinsurance for the hip replacement. You say that your deductible and yearly 
maximum had already been met. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 10% 
coinsurance for surgery services after the deductible is met.  
 
The file shows that at the time of service, your out-of-pocket maximum had not been met. Therefore, you have 
been asked to pay a total of $353.10, which is less than the 10% coinsurance for the hip replacement. This 
amount is lower since this amount was the remaining amount to meet the out-of-pocket maximum. The hip 
replacement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers 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 a 
hip replacement procedure performed on December 15, 2021.