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

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for date of service 
April 28, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was reported correctly. The Plan denied 
your request. The Plan says this service is not supported as billed. 
 
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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the medical documentation 
does not note the amount of time spent providing this service. Without this information, a time-based code such 
as 99291 cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical 
care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour 
(99291) billed for date of service April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you do 
not need care that can only be given in a hospital setting. 
 
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 physician 
reviewer found that you presented to the acute hospital with fever and chills due to urosepsis and a stage 4 
sacral pressure ulcer. You are receiving an appropriate level of care in the present setting. The provided records 
do not explain what care services will be provided in the LTACH that are not available in the present hospital 
setting. The acute hospital can provide for all your present inpatient care needs, and the health plan has not 
stated that continued care in the acute hospital will not be covered. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on June 18, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you are requesting reconsideration the 
claim. 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 $265 
copayment for ambulance services.  
 
 
 
 
 
 
 
 
 You have been asked to pay $265 copayment for ambulance. This item/service falls within the 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 ambulance provided on 
June 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basivertebral nerve ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested procedure is not an accepted standard of medical practice for the diagnosis 
or treatment of back pain. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this procedure is considered experimental/investigational at the present time.  Therefore, the request 
is deemed not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve basivertebral nerve ablation for the enrollee.
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 you need transportation 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per 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 12 trips per year.  
 
   
We looked at your request, the records in the case file, and the rules. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx (81551) provided on June 3, 2022. 
 You asked the Plan to pay for ConfirmMDx. You say that the service was medically necessary. The Plan 
denied your request. The Plan says there is no evidence that there was any clinical change that supports 
ordering the test. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx is covered under specific conditions. 
 
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 ConfirmMDx. Our reviewer says that the 
ConfirmMDx was not medically necessary. Our physician reviewer found the provided documentation does not 
indicate a clinical change that supports ordering the test. Therefore, the reviewer found that the ConfirmMDx 
was 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 ConfirmMDx have not been met. Therefore, we decided that the Plan does not 
have to pay for the ConfirmMDx (81551) provided on June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump supplies provided from June 21, 2021, to 
June 27, 2021. 
 
You asked the Plan to pay for the billed services. You say that medical documentation supports the services. 
The Plan denied your request. The Plan says the items are non-covered. 
 The Plan must follow Medicare rules. Medicare rules say that external infusion pumps are only covered under 
certain medical indications.  
 
We looked at the file, and Medicare rules. Disposable delivery drug systems (A4305) are non-covered devices. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the infusion pump supplies provided from 
June 21, 2021, to June 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee needs this procedure due to 
worsening heart failure. The Plan denied your request. The Plan says this device has been determined to be of 
uncertain value and carries a significant risk of complication including death and severe injury. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes establishing the value of CardioMEMS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat echocardiography, transthoracic (TTE) (93306). 
 
You asked the Plan to pre-approve a repeat TTE. You say that you feel your doctor should know what your 
insurance provider is liable for. You also say that you will do whatever your doctor tells you to do. The Plan 
denied your request. The Plan says the requested service is not medically necessary. 
 
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 repeat TTE. Our reviewer says that 
the requested repeat TTE is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not indicate a change in status that would support the medical 
necessity of a repeat TTE at this time. Therefore, the reviewer found that a repeat TTE is not medically 
reasonable or necessary at this time. 
 
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 repeat TTE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat echocardiography, transthoracic (TTE) (93306).
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 service requested is medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF 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 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 medical records provided there is no documentation that the 
enrollee requires daily skilled nursing or therapy services. There is also no documentation that the enrollee 
requires these services on an inpatient basis, only in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 IRF is better to assist, and you need 
more intense therapy. The Plan denied your request. The Plan says the request is not medically necessary, when 
you are ready to leave the hospital, you can safely receive this care in another setting, such as a Skilled Nursing 
Facility (SNF). 
 
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 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: 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 records provided support the need for 
the requested device. The Plan denied your request. The Plan says a home mechanical ventilator set in TTV-
VAPS mode with Auto-EPAP that could be delivered by bilevel positive airway pressure (BiPAP) is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  The enrollee has severe chronic obstructive pulmonary disorder (COPD), and arterial 
blood gas (ABG) as an outpatient confirms chronic carbon dioxide (CO2) retention.  The enrollee may benefit from bilevel positive airway pressure (BiPAP) with average volume assured pressure (AVAPS) during sleep. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says These services are available with a participating 
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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by the requested out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the records provided support the 
need for inpatient psychiatric care. The Plan denied your request. The Plan says the clinical information 
provided does not support that the criteria for coverage have not been met. 
 
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 psychiatric care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted 
to the acute inpatient psychiatric hospitalization on October 28, 2022, with Schizoaffective Disorder, 
Depressed Type and Major Depressive Disorder, Recurrent Episode, Severe. It was not expected this enrollee 
would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or 
visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as he did not have dangerousness to self or others, perceptual disturbance including 
delusions, auditory or visual hallucinations. This enrollee did not appear to require inpatient mental health 
treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that 
active treatment was taking place. It did not appear that the services were reasonably expected to improve the 
patients condition or for the purpose of diagnosis. 
 
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 psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for residential rehabilitation. 
 
You asked the Plan to pre-approve inpatient admission for residential rehabilitation. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
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 admission for residential 
rehabilitation. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based upon review of the records provided you do not meet criteria for acute inpatient residential rehabilitation treatment as you were not shown to be a danger to yourself or others. There were no auditory or visual 
hallucinations and was not showing any withdrawal symptoms. You were noted to be cooperative and 
compliant with treatment while not showing any aggressive behaviors. 
 
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 admission for residential rehabilitation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve inpatient admission for residential rehabilitation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that your dentures do not fit right. You say that 
they do not match the bottom denture. You say that you would prefer implants instead of dentures. You also 
say that you can only eat soft food. The Plan denied your request. The Plan says your benefit for the requested 
complete upper denture has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested complete upper denture was exhausted on date of service March 19, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).