Persius/hicric huggingface dataset:
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 is currently still in the hospital for 
occupational therapy. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for admission to an IRF. 
 
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 clinical documentation shows that the enrollee has active pain management needs and requires close medical monitoring however therapy evaluations show poor tolerance due to pain 
(enrollee refusing activities and sessions) thus would not be expected to tolerate intense therapy and does not 
meet IRF criteria. Inpatient rehabilitation not medically 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on April 17, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no documentation to support the medical necessity of this transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that other means of transport (such as stretcher van or wheelchair van) were 
contraindicated for this patient on 4/17/22. The documentation does not support that the patient needed the 
expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can 
provide for safe transport on 4/17/22. The documentation does not support that the ambulance transport on 
4/17/22 was medically reasonable and necessary for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on April 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound (93971) provided on April 1, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this was a routine service. The 
Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed 
in accordance with your contract. 
 
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 $100 
copayment for Medicare-covered radiological diagnostic services other than x-rays.  
 
You have been asked to pay a $108.25 copayment for the ultrasound. An ultrasound falls within the Medicare-
covered radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the ultrasound (93971) provided on April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87633) provided on April 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 87633 is not supported in the medical record. Specifically, the lab services 
must be billed with the date that the specimen was collected. In this case, the records show that the specimen 
was collected on April 11, 2022. This means that the claim was billed with the incorrect date of service. 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 pay for the lab services (87633) provided on April 12, 2022.
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. You say that the enrollee needs LTACH level of care 
for continued care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for LTACH care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and should only require short-term additional 
acute care services that can safely be administered at the current facility until more appropriate for 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 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: 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 the enrollee's care can be provided in a less intensive 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. The 
enrollee is medically stable with no medical complexity for physical medicine and rehabilitation physician's 
supervision 3 times a week in an IRF. There are no acute rehab nursing needs identified or documented. The enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per 
week with multidisciplinary approach in an IRF. While the enrollee may benefit from continued physical and 
occupational therapy, the enrollee's rehab needs can be safely provided in a lower intensity and alternate 
setting. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), extra-spinal chiropractic 
manipulative treatment (98943), electrical stimulation (G0283), manual therapy (97140), therapeutic exercises 
(97110), and the self-care home management training (97535) provided from April 4, 2022, through April 6, 
2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services provided do not meet Medicare criteria for coverage of chiropractic services 
and therefore, are not covered under the Plans contract.  Therefore, we decided that the Plan does not have to pay for the office visit (99202), extra-spinal chiropractic 
manipulative treatment (98943), electrical stimulation (G0283), manual therapy (97140), therapeutic exercises 
(97110), and the self-care home management training (97535) provided from April 4, 2022, through April 6, 
2022.
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. You say that the enrollee meets criteria for LTACH 
admission. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. 
 
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 that the enrollee appears to be stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for continuous positive airway pressure (CPAP) 
on February 24, 2022, to March 24, 2022. 
 
You asked the Plan to waive the deductible for CPAP. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to Durable Medical Equipment (DME) 
and Related Supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
Medical Equipment (DME) and Related Supplies. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $250 deductible which applies to Durable Medical Equipment (DME) and Related 
Supplies. This cost sharing is a contractual obligation that had not been met at the time CPAP was received on 
February 24, 2022, to March 24, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for continuous positive airway pressure (CPAP) on February 24, 2022, to March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
April 11, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the transportation 
was necessary, and you do not know why your copayment is so high. The Plan denied your request. The Plan 
says the proper copayment was applied for the service that was rendered. 
 
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 $440 
copayment for each Medicare-covered one-way trip by ground ambulance.  
 
  You have been asked to pay a $440 copayment for the ambulance transportation. The ambulance transportation 
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 
the ambulance transportation provided on April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says the 
enrollee's care can be treated at an observation level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights.  
 
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 services. Our physician 
reviewer found that the enrollee has chronic obstructive pulmonary disease (COPD). He presented to the 
emergency department with shortness of breath and cough. He was treated with continuous positive airway 
pressure, bronchodilators, oxygen support, and steroids with benefit. He was afebrile with stable vitals.  
He was diagnosed with a mild COPD exacerbation. There were no other complexities of the case to suggest the 
patient would likely require hospital services that would cross 2 midnights. 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a power wheelchair provided on May 11, 
2022. 
 
You asked the Plan to waive the coinsurance for a power wheelchair. You say that you were told by the 
provider there were no charges for the wheelchair. You say that you don't want to pay the bill because of what 
the representative told you and you want to file a complaint. The Plan denied your request. The Plan says you 
have been charged the correct coinsurance 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 20% 
coinsurance for all plan-approved, Medicare-covered motorized wheelchairs and electric scooters.  
 
You have been asked to pay $711.25, which is 20% of the allowed amount for the power wheelchair. The 
allowed amount is $3556.26 (20% x $3556.26 = $711.25). The power wheelchair falls within the Durable 
Medical Equipment (DME) Related 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 coinsurance for a power wheelchair provided on May 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the bone density study provided on March 
28, 2022. 
 
You asked the Plan to waive the copayment for the bone density study. You say that the bone density has no 
copayment and you do not want to pay for this bill. The Plan denied your request. The Plan says the copayment 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each Medicare-covered x-ray.  
 
  You have been asked to pay a $40 copayment for the bone density study. The bone density study falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The bone density 
study is considered an x-ray. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the bone density study 
provided on March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on October 26, 2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 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 $90 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests  radiological diagnostic services, not including 
x-rays.  
 
 
 
 You have been asked to pay a $90 copayment for ultrasound. Ultrasound 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 ultrasound on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is experimental and non-covered. 
 
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 interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the requested 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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11042 billed for date of service January 1, 
2022. You asked the Plan to pay for procedure code 11042. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11042 is 1. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 11042 billed for date of 
service January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more coverage for endodontic therapy on tooth #14 
(D3330). 
 
You asked the Plan to pre-approve more coverage for the dental services. You say that the Plan should pay the 
total 50% of the upcoming claim since you were not told the correct coverage. The Plan denied your request. 
The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. 
 
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. 
 
According to your pre-determination for endodontic therapy you may be asked to pay the difference between 
the out-of-network providers charges and the Plans payment. 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 pre-approve 
more coverage for endodontic therapy on tooth #14 (D3330).