Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional physical therapy visits. 
 
You asked the Plan to pre-approve 3 additional physical therapy visits. You say that you have been receiving 
services for over 25 years. You say that the services have saved you from deformities and surgeries otherwise 
subjected to. The Plan denied your request. The Plan says the requested visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
  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 3 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that you have had extensive therapy and do not 
require ongoing skilled therapy. You can transition to a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on January 20, 2022. 
 
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 billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the testing services rendered on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pain specialist office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the pain specialist office visit. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the pain specialist office visit. We found no exception that would require the Plan to 
pre-approve the pain specialist office visit. Therefore, we decided that the Plan does not have to pre-approve 
the pain specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 3, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that the referring provider listed on the claim did not order the test provided. This 
means the genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 4, 2022, to February 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you had no cost for a previous 
inpatient stay in 2019. 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 $325 per 
day for days 1-5 and $0 per day after day 5 for each inpatient stay.  
 
The file shows that you were in the hospital from February 4, 2022, to February 7, 2022. Therefore, you have 
been asked to pay $375 per day for the first 3 days of inpatient care. The total for your stay is $975 ($325 
copayment x 3 days = $975). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from February 4, 2022, to 
February 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on February 8, 
2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be 
responsible for the copayment because you were not treated. The Plan denied your request. The Plan says you 
must pay a $120 copayment. 
 
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 $120 
copayment for Emergency Care.  
 
 
 
 
 
 
 You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency Care 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 
emergency room visit on February 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that more transportation trips 
are needed in order to get to your medically necessary dialysis appointments for treatment of your end stage 
renal disease. The Plan denied your request. The Plan says you have exhausted your allowed trips for the year. 
 
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 60 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have received coverage for more than 60 one-way routine transportation trips in the 2022 calendar year. Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF admission. 
 
You asked the Plan to pre-approve continued SNF admission. You say that the family believes you require a 
longer stay in a skilled nursing facility due to a COVID-19 diagnosis. The Plan denied your request. The Plan 
says your request is not medically 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 continued SNF admission. Our 
reviewer says that there is no documentation that you require the services on an inpatient basis, only in a skilled 
nursing facility. Our physician reviewer found you are a 94 year old female with a past medical history of 
hypertension, hypothyroidism, neuralgia, a hiatal hernia and acid reflux who was admitted to an acute hospital 
with dehydration and low blood pressure.  
 
You were treated in the hospital and then transferred to a skilled nursing facility for skilled nursing and therapy 
services on July 21, 2022. You were weak and deconditioned and was working with speech, physical and 
occupational therapy in the facility. As of July 28, 2022, it is reported that you were walking 125 feet with a 
two wheeled walker with stand-by assistance and was stand-by assist for transfers and most activities of daily 
living. On August 2, 2022, you tested positive for COVID-19. Records reported unremarkable with regard to 
nursing assessment on August 2, 2022 after the COVID-19 test. You were on outpatient medications and a 
regular diet. The last covered day in the skilled nursing facility for skilled nursing and therapy services was 
August 1, 2022. You do not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found you do 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 continued SNF admission have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary, as you are afraid of 
falls. The Plan denied your request. The Plan says the documentation does not include a face-to-face evaluation 
by a provider which addresses the criteria listed above, or a home evaluation. 
 
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.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable and necessary. Our physician reviewer found that the 
mobility evaluation states that you are able to ambulate distances of 300 feet with a cane, and there is no 
specific documentation of activities of daily living that you have difficulty with. The criteria for this device has 
not been met, and is medically unnecessary.  
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on March 
25, 2022. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you should not have to pay 
this copayment as you were seeing the provider that day. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
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 $75 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay the allowed amount of $14.35, which is less than the $75 copayment for an 
electrocardiogram. An electrocardiogram 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 electrocardiogram 
provided on March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that Medicare does not consider this to be 
investigational and the enrollee meets the indications for this procedure. The Plan denied your request. The 
Plan says the Vertiflex device has not been shown to be safe and effective in long-term studies. 
 
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 the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and 
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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 
14, 2021, to July 12, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the initial 
request for anticipated payments (RAP) claim was not provided within five calendar days from the start of care. 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from June 14, 2021, to July 12, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from June 25, 2021, to July 24, 2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. In this case, the Plan has denied because a core-based statistical area (CBSA) 
number is required to be submitted with the claim under value code 61. The claims available in the case record 
provide a CBSA number of 26420 under value code 61. The Plan has not provided an argument as to why the 
number is not valid. It is the Plan's responsibility to substantiate its denial. In this case, the denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for home health 
services provided from June 25, 2021, to July 24, 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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that medication management and transfusion services are 
not available at the skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for an IRF admission. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 pay for the services (A9585, 88311 88342 88173 88341, 99205 
G0463) provided on January 4, 2022, to February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services (A9585, 88311 88342 88173 88341, 99205 G0463) 
provided on January 4, 2022, to February 10, 2022, by an out-of-network (OON) provider.
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 needs to be transferred to an IRF, as he 
lives alone and is unable to go home to an empty house. You say that the enrollee has been in the hospital for 
14-days and needs to be transferred immediately so that he can regain maximum function. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's 
needs may be met in the hospital setting. 
 
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. The enrollee 
was admitted for obstructive uropathy, urinary tract infection, and sepsis. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.