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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient's functional level requires this therapy on an intensive IRF level.  
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that medical need for IRF care 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the 
enrollee requires at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy 
services. The documentation supports that therapy services can be provided at a lower level of care. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post stabilization care from 11:22 am on 07/26/21 to 11:45 
am on 07/27/21. 
 
You asked the Plan to pay for post stabilization care. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee was hemodynamically 
stable for ambulance transport with oxygen and monitoring to a Plan facility as of 11:21 am on 07/26/21. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post stabilization care from 11:22 am on 07/26/21 to 11:45 am on 07/27/21.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on July 21, 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 billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
 We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular panel provided on June 22, 2021. 
 
You asked the Plan to pay for the cardiovascular panel. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this testing was not ordered by the 
member's physician. 
 
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. The rules also say that all diagnostic x-ray tests, 
diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the 
beneficiary. 
 
The test at issue in this appeal, the cardiovascular panel, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Specifically, the record indicates that these services were 
not ordered by the member's treating physician. Therefore, we decided that the Plan does not have to pay for 
the cardiovascular panel provided on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
June 23, 2021. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that the services should 
be covered in full and you feel they were billed erroneously. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Outpatient hospital services.  
 
 
  You have been asked to pay a 20% coinsurance for the electrocardiogram (EKG) (allowed is $20,368.76 x 20% 
= $4,073.75) . Electrocardiograms fall within the 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 to waive the copayment for an electrocardiogram (EKG) provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive eyeglasses provided on May 5, 2021. 
 
You asked the Plan to pay for the progressive eyeglasses. You say that the item should be covered. The Plan 
denied your request. The Plan says you received Tier 4 lenses which is the higher progressive lenses which is 
not fully covered on your plan which generated the extra charges. The second pair of eyeglasses you purchased 
were outside of your benefit since member one pair of eyeglasses per calendar year is allowed. 
 
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 these services when you pay $0 for one pair of Medicare-covered standard 
eyeglasses with standard frames or contact lenses after cataract surgery when obtained from a provider in the 
EyeMed Vision Care network. You will pay any cost over the Medicare-allowed charge if you purchase 
upgraded frames.. 
 
We looked at the file and the Plan's rules. You purchased Tier 4 progressive eyeglasses which generated 
additional charges. Based on this information, we decided that the Plan's rules for coverage of the progressive 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the progressive 
eyeglasses provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a nuclear medicine positron emission 
tomography (PET) scan, regadenoson injection, and aminophyllin injection provided on June 11, 2021. 
 
You asked the Plan to waive the cost sharing for a PET scan, regadenoson injection, and aminophyllin 
injection. You say that you do not know why the doctor performed this test. You also say that you were not 
prescribed medication. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for advanced imaging services in a specialist's office. The Plan contract also says that enrollees 
must pay 20% coinsurance for part B drugs. 
 
You have been asked to pay a $180 copayment for a PET scan. A PET scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have been asked to pay $47.45, 
which is 20% of the allowed amount for a regadenoson injection ($237.24 allowed amount x 20% coinsurance 
= $47.45). You have also been asked to pay $1.90, which is 20% of the allowed amount for an aminophyllin 
injection ($9.50 allowed amount x 20% coinsurance = $1.90). A regadenoson injection and aminophyllin 
injection fall within the Medicare Part B Prescription Drugs benefit category. These are drugs that were given 
as part of your PET scan. You have been asked to pay a total amount of $229.35 for a PET scan, regadenoson 
injection, and an aminophyllin injection. ($180 copayment + $47.45 coinsurance + $1.90 coinsurance = 
$229.35). 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 cost sharing for a nuclear medicine positron emission 
tomography (PET) scan, regadenoson injection, and aminophyllin injection provided on June 11, 2021.  
 
Your complaint about the doctor not explaining why you needed these tests is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the family feels these services are necessary for the 
enrollee. The Plan denied your request. The Plan says that the patient would be safely and equally well served 
with skilled therapy services at an alternative level of care. 
 
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.  The patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires 
at least 3 hours a day for 5 days a week, or 15 hours over 7 consecutive days, of therapy services.  It has not 
been established that there is 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. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance services for dialysis 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 enrollee is able to sit in a dialysis recliner without incident. 
 
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 pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee sits in 
a recliner for dialysis. The review has determined that the documentation does not support that other means of 
transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) are contraindicated 
for this enrollee. The documentation does not support that the enrollee needs 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 for dialysis is medically reasonable and 
necessary for the enrollee. 
 
 
  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 ambulance services for dialysis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning (99497) provided on May 26, 
2021. 
 
You asked the Plan to pay for the advance care planning (99497). The Plan denied your request. The Plan says 
CPT codes 99223 and 93010 have been overturned. The Plan also says that CPT code 99497 is included in 
CPT code 99223 and cannot be separately reimbursed. 
 
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, we have confirmed that code 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the advance care planning (99497) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on October 1, 
2021. 
 
You asked the Plan to pay for the AWV. You say that you saw this provider so that you could have medical 
records that would allow you to get a pain management prescription. The Plan denied your request. The Plan 
says you already had an annual wellness visit on March 29, 2021, so you were not entitled to another one when 
you had the visit on October 1, 2021. The Plan must follow Medicare rules. These rules say that enrollees are 
eligible for coverage of an AWV once every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on 
October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says LTACHs do not provide clinical advantage over non-LTACH acute care 
hospitals. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 15, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that service was provided to the enrollee so the 
claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider with no referral from an in-network provider or an approved authorization. Also, the services rendered 
was not urgent or emergent. 
 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 laboratory services provided on November 15, 
2021, by an out-of-network (OON) provider.