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

 
We decided that the Plan does not have to remove the $89.38 applied to your deductible for physical therapy 
services provided on February 7, 2022. 
 
You asked the Plan to remove the $89.38 applied to your deductible for physical therapy services provided on 
February 7, 2022. You say that you do not agree to this charge and want it removed. The Plan denied your 
request. The Plan says you are responsible for your cost share. 
 
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 $750 deductible which applies to Outpatient Rehabilitation Services.  
 
 
 
 
 
 
 The item or service you asked the Plan to remove the $89.38 applied to your deductible falls within the benefit 
category Outpatient Rehabilitation Services. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $750 deductible which applies to Outpatient Rehabilitation Services. This cost sharing is a 
contractual obligation that had not been met at the time for physical therapy services was received on February 
7, 2022. Therefore, we decided that the Plan does not have to remove the $89.38 applied to your deductible for 
physical therapy services provided on February 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $275 copayment for an ambulance transport provided on 
December 27, 2021. 
 
You asked the Plan to waive your $275 copayment for an ambulance transport provided on December 27, 
2021. You say that you did not know about copayments. The Plan denied your request. The Plan says you must 
pay a $275 copayment, each way, for in-network Medicare-covered ambulance services. 
 
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 $275 
copayment for Ambulance Services.  
 You have been asked to pay a $275 copayment for an ambulance transport provided on December 27, 2021. An 
ambulance transport 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 your $275 copayment for an ambulance transport provided on December 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health visit provided on 
February 15, 2022. 
 
You asked the Plan to waive the copayment for the mental health visit. You say that you were told it would be 
a $30 copayment so that's all you are willing to pay. The Plan denied your request. The Plan says the 
copayment applied 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 $55 
copayment for each out of network Medicare covered individual or group therapy visit.  
 
 
 
 You have been asked to pay $55 copayment for the mental health visit. Mental health visits fall within the 
Outpatient mental health 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 the mental 
health visit provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your cost share for services rendered on January 20, 2022, and 
February 17, 2022. 
 
You asked the Plan to waive your cost share for an office visit and surgery services rendered on January 20, 
2022, and February 17, 2022. You say that you were told that the provider was in-network. The Plan denied 
your request. The Plan says you have a $1500 deductible. The Plan also says you must pay a 40% coinsurance 
for provider and professional services. 
 
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 $1500 
deductible for Physician/Practitioner Services, Including Doctor's Office Visits.  Your contract with the Plan also clearly says that you must pay a 40% coinsurance for out-of-network provider 
and professional services. 
 
You have been asked to pay $529.82 for an office visit and surgery services on January 20, 2022. This amount 
was applied to your deductible. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. You have also been asked to pay a $127.23 coinsurance for surgery services performed 
on February 17, 2022. For services rendered on this date, the Plans allowance was $318.06. You are 
responsible for $127.23 ($318.06 x 40% = $127.23) as a 40% coinsurance was applied because the services 
were performed by an out-of-network provider. 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 your cost share for 
services rendered on February 17, 2022.  
 
Your complaint about being given incorrect information about the network status of the provider 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cortisone injection performed on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for the injection. You say that this was only an injection, not 
surgery. 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 $250 
copayment for surgery or services provided at an outpatient hospital facility.  
 
 
 
 
 
 
 You have been asked to pay a $250 copayment for the injection. The injection falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a cortisone injection performed on December 
10, 2021.
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 your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you 
may benefit from physical therapy and occupational therapy, the rehabilitation needs may be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental pneumatic appliance, trunk (E0656) provided 
September 1, 2021. 
 
You asked the Plan to pay for a pneumatic appliance. You say that you are appealing the intended reduction of 
benefits. You feel this reduction is an error in processing of the claim. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD appliance have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral 
artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have 
to pay for the segmental pneumatic appliance, trunk (E0656) provided September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
August 14, 2021, to September 17, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you have already paid $1,560 
and any additional amount should be worked out between the insurance and the provider. 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 $390 per 
day for days 1-5 and $0 per day for days 6-90 for each inpatient admission.  
 
The file shows that you were in the hospital from August 14, 2021, to September 17, 2021. Therefore, you have 
been asked to pay $390 per day for the first 5 days of inpatient care. The total for your stay is $1,950 ($390 
copayment x 5 days = $1,950). 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 August 14, 2021, to September 17, 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. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. Consequently, the requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
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 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. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is unable to care for herself at all. The 
Plan denied your request. The Plan says the enrollee's current needs can be managed at a lower level of care 
like a skilled nursing facility. 
 
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 documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires 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 /5 days 
a week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that the enrollee 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.
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 admission to long-term acute care is the 
best opportunity for continued improvement and recovery from ongoing medical conditions. The Plan denied 
your request. The Plan says the record shows that guidelines are not met for this request. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. The clinical assessment at this time 
does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. 
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation supports that the complexity of the patient's nursing, medical and rehabilitation needs 
requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care needs can be met in a lower level of care, such as a skilled nursing facility. 
 
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 documentation does not support that you require at least 3 hours a day /5 days a 
week, or 15 hours over 7 consecutive days, of therapy services. While you may be able to participate in and benefit from an intensive rehabilitation therapy program, the documentation supports that a less intensive 
therapy program would be appropriate. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced care planning (99497) provided on July 23, 2021. 
 
You asked the Plan to pay for advanced care planning. You say that this is supported in the records. The Plan 
denied your request. The Plan says this is not documented. 
 
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 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, the submitted records do not 
include documentation of advanced care planning. Based on this information, we decided that Medicare rules for coverage of advanced care planning have not been met. Therefore, we decided that the Plan does not have 
to pay for advanced care planning (99497) provided on July 23, 2021.