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 you are in need of rehabilitation due to undergoing 
hip replacement surgery. You state that the hospital will no longer be caring for you and will send you home 
with many limitations leaving you immobile. You state that you are requesting rehabilitation to attain physical 
therapy and gain knowledge of completing daily tasks in a safe manner and if you are sent home, you may fall 
and re-injure the hip resulting in another hospital visit. The Plan denied your request. The Plan says the stay is 
not medically necessary based on IRF criteria. The Plan states you can safely receive the services you need in 
other settings, for example: a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions 
are stable on outpatient medications with no issues that require a physicians evaluation three (3) or more times 
per week. You do require physical therapy and occupational therapy services, but the medical records provided 
do not clarify why you require an intensive inpatient rehabilitation therapy program. Provided records do not 
explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower 
level of care such as in a skilled nursing facility (SNF) is not appropriate for you. There is no documentation 
that you require the intensive rehabilitation therapy program provided in an IRF. Care at the SNF level appears 
to be appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient hospital facility visits and a 
duplex scan of aorta provided from April 9, 2020, to November 8, 2021. 
 
You asked the Plan to waive the copayments for outpatient hospital facility visits and a duplex scan of aorta. 
You say that you were not informed of the charges for over a year and a half and disagree with how the claims 
were processed. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct 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 $40 
copayment for services rendered by a physician specialist in an outpatient hospital setting and a $5 copayment 
for diagnostic procedures and tests. 
 
You had outpatient hospital facility visits from April 9, 2020, to November 8, 2021, for a total of 25 visits. 
Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $1,000.  
 
You received a duplex scan on November 5, 2021. Therefore, you are responsible to pay the $5 copayment.   
 
The total amount you owe is: $1,005.  
 
You have been asked to pay the total copayment amount of $1,005 for outpatient hospital facility visits and a 
duplex scan of aorta. Outpatient hospital facility visits fall within the outpatient hospital services benefit 
category. A duplex scan of aorta 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 copayments for outpatient hospital facility 
visits and a duplex scan of aorta provided from April 9, 2020, to November 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 6, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee isn't ready to go home. The 
Plan denied your request. The Plan says your request does not meet Medicare guidelines because the enrollee 
no longer requires skilled services and the continuation of SNF is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are no longer necessary. Our physician reviewer found that the enrollee did not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse after March 6, 2022. The enrollee did not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist after March 6, 2022. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting after March 6, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing facility (SNF) care after March 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 26, 
2021. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that the charge should be 
included with your ER visit on July 28, 2021. 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 $60 
copayment for urgently needed care.  
 
You have been asked to pay a $60 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 urgent care visit provided on July 26, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the SNF services provided from August 1, 2021, 
through August 13, 2021. 
 
You asked the Plan to waive the copayment for SNF services. You say that customer service stated the cost 
should have been $400. You say that it has been verified $400 is the correct amount and you are appealing the 
$600 charge. The Plan denied your request. The Plan says that the copayment applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says you were in a skilled nursing facility for a total of 28 days. The 
documentation submitted does not support there were 20 SNF days within the benefit period prior to August 1, 
2021. Therefore, we decided that the Plan has to waive the copayment for the SNF services provided from 
August 1, 2021, through August 13, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you 
received on May 6, 2021. 
 
You asked the Plan to waive the copayment for the ER services. You say that the Plan should review the 
medical records and pay this bill. The Plan denied your request. The Plan says you were charged this 
copayment 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 $90 
copayment for emergency room services.  
 
 
 You have been asked to pay a $90 copayment for the ER services. 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 emergency room (ER) services you received on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the raised toilet seat (E0244) over the bed table (E0274) 
miscellaneous durable medical equipment (E1399) and sales tax (S9999) purchased July 8, 2021 to October 4, 
2021. 
 
You asked the Plan to pay for the medical equipment. You say that due to recent hospitalizations due to falls 
you had to purchase the durable medical equipment to help prevent future falls or injuries. The Plan denied your request. The Plan says the medical equipment from suppliers that is not certified with Medicare. The 
purchased items are not covered items. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The items at issue in this appeal are hygienic items or are items that do not serve a purpose that is 
primarily medical in nature.  Therefore, we decided that the Plan does not have to pay for the raised toilet seat 
(E0244) over the bed table (E0274) miscellaneous durable medical equipment (E1399) and sales tax (S9999) 
purchased July 8, 2021 to October 4, 2021.
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 states the 
enrollee could receive care in another setting and the Plan could review alternate settings if requested, such as 
skilled nursing facility, outpatient setting or home health 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. Our 
physician reviewer found the review has determined that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care.  The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the drug testing (G0482). We decided that the Plan does not have to 
pay for specimen handling and conveyance (99000).  
 
You asked the Plan to pay for the drug testing (G0482). You say that this claim should be paid as billed. The 
Plan says that it was found that code G0482 is not appealable. Code 99000 is correctly denied as it is not 
separately payable. 
 
We decided that the Plan has to pay for the drug testing (G0482).  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The code was denied on October 25, 2021, for requested information not being received. That such information 
was received as an appeal request would not exempt the code from an appeal determination. Since the Plan 
forfeited the opportunity to provide a valid denial rationale, we find that the denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the drug testing (G0482).  
 
We also decided that the Plan does not have to pay for specimen handling and conveyance (99000). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99000 has a status indicator of B on the Physician Fee Schedule. This means that payment for this 
service is always bundled into payment for other services. Therefore, we decided that the Plan does not have to 
pay for specimen handling and conveyance (99000). 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device. 
 
You asked the Plan to pre-approve a Cala Trio nerve stimulator device. You say that the requested device is 
medically necessary. You say that the enrollee has a severe tremor in her wrist and this would help control it 
better than medication. You say that the enrollee has tried using medication to treat her condition and it has not 
worked. You say that stronger medication makes her drowsy. The Plan denied your request. The Plan says the 
requested device is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary. 
 
We looked at the file and Medicare rules. The records show that the requested device is being requested to treat 
the enrollee's essential tremor. Based on this information, we decided that Medicare rules for coverage of a Cala Trio nerve stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Cala Trio nerve stimulator device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a telehealth visit provided on November 16, 
2020. 
 
You asked the Plan to waive the deductible for a telehealth visit. You say that this service was medically 
necessary. You say that there isn't another psychiatrist within a 30-mile radius of your home. The Plan denied 
your request. The Plan says the deductible applied was 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 $750 deductible which applies to out-of-network outpatient mental 
health care.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient mental health care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient mental health care. This cost sharing is a contractual obligation that had 
not been met at the time a telehealth visit was received on November 16, 2020. Therefore, we decided that the 
Plan does not have to waive the deductible for a telehealth visit provided on November 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this service should be 
covered in full because it was medically necessary. The Plan denied your request. The Plan says you were 
charged this copayment 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 $290 
copayment for ambulance services.  
 
You have been asked to pay a $290 copayment for the ambulance services. This copayment applies regardless 
of the reason for the service.  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 services you received on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural lysis of adhesions. 
 
You asked the Plan to pre-approve epidural lysis of adhesions. You say that the requested procedure is 
medically necessary and supported by the records provided. The Plan denied your request. The Plan says the 
requested procedure has not been proven by research to be helpful treatment for back pain. The Plan says that 
the requested procedure is considered experimental and investigational. 
 
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 epidural lysis of adhesions. Our 
reviewer says that epidural lysis of adhesions is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered an experimental/investigational technique. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural lysis of adhesions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural lysis of adhesions.
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 you will benefit and improve with 
LTACH services and cannot adequately be cared for in your current condition at a skilled nursing facility. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for coverage. 
 
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 are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. 
 
 
 
 
 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.