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 you are appealing with supporting records. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings, 
such as 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that 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: 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 BiPAP was tried and failed in the 
hospital. You say that the requested ventilator is not being used to provide CPAP or bi-level PAP therapy. You 
say that you require the requested ventilator for treatment of chronic respiratory failure secondary to obesity 
hypoventilation syndrome. The Plan denied your request. The Plan says use of a portable ventilator to deliver 
ventilatory support via settings that could be equally provided by a BiPAP with AVAPS settings is inconsistent 
with the coverage rules. 
 
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 a portable ventilator is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized for acute on chronic hypoxic and hypercarbic respiratory failure.  There is a diagnosis of obesity-
hypoventilation syndrome (OHS) and the enrollee is on chronic narcotics.  The enrollee does not have 
diagnoses of chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, or generalized 
neuromuscular disease.  There is a diagnosis of paraplegia and spinal stenosis is mentioned, but no evidence is 
provided that diaphragm function is impaired.  Medicare does not cover a home ventilator for OHS.  The 
appropriate treatment is CPAP or BiPAP.  This enrollee was intolerant of the CPAP interface previously, so it 
is unlikely he will tolerate the ventilator interface. 
 
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: 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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the enrollee can safely receive the care needed in another 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 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 somewhat unstable still requiring high flow oxygen and 
should only require short-term additional acute care services that can be safely provided at the current facility 
until more stable and 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 LTACH is not medically necessary as 
the enrollee is still somewhat unstable and as it would not be clinically advantageous. Completion of treatment 
at the current location 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit provided on February 11, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you shouldn't be charged this for a ten-
minute office visit. The Plan denied your request. The Plan says the deductible applied 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 $203 deductible which applies to Physician/Practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $203 deductible which applies to Physician/Practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time 
office visit was received on February 11, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for office visit provided on February 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) 
provided on March 6, 2022. 
 
You asked the Plan to pay for ambulance response without transport. You say that you feel you should not be 
responsible for this bill, as the medical technician where you reside called the ambulance without your 
knowledge when there was no emergency situation. The Plan denied your request. The Plan says the 
ambulance benefit is a transportation benefit. When no transport is provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport (A0998) provided on March 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission. 
 
You asked the Plan to pay for an inpatient hospital admission. You say that the enrollee is high risk because she 
has chronic obstructive pulmonary disease and because of other health factors. The Plan denied your request. 
The Plan says there is not documentation provided to support the expectation that the enrollee will require a 
greater than 2 midnight stay. 
 
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. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found detailed documentation is not evident regarding the clearance (from her 
pulmonologist or re. an echo study) indicating that she is at increased risk for perioperative complications. 
There are no other noted significant past and/or current medical history that would place this enrollee at 
increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the record does not show that at the time of the request for an inpatient admission, the 
requesting physician reasonably expected that the enrollees necessary hospital care would span two 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 an inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pay for an inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this device is medically necessary. The 
Plan denied your request. The Plan says the record does not show you satisfy the criteria for the power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the requested power wheelchair is not medically reasonable and necessary. Our physician reviewer found 
you are a 74-year-old male with mobility impairments related to post-polio syndrome currently using a manual 
wheelchair. In this case, clinical documentation states that you are able to use a manual wheelchair without 
difficulty and there is no further documentation to show that you would require a power mobility device to increase independence with activities of daily living. As you can operate a manual wheelchair successfully, 
there is no medical need for the power wheelchair per Medicare rules. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted laboratory service provided on January 26, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the unlisted laboratory service. You say that the service was medically necessary. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
unlisted laboratory service. We found no exception that would require the Plan to pay for the unlisted 
laboratory service. The records provided for review do not show that the unlisted laboratory service was urgent 
or emergent. Therefore, we decided that the Plan does not have to pay for the unlisted laboratory service 
provided on January 26, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram, routine ECG provided on  
November 4, 2020. 
 
You asked the Plan to pay for an electrocardiogram, routine ECG. The Plan denied your request. The Plan says 
Medicare denies a claim if it is not received by the plan within 12 months or 1 calendar year from the date 
when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an electrocardiogram, routine ECG was not filed until March 4, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an electrocardiogram, routine ECG provided on 
November 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from April 
6, 2021, to April 9, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this was the only hospital 
close that you could go to so you should be charged in-network. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $360 copayment per day for day 1 through 5 of in network care.  
 
 
 
 The enrollee has been asked to pay $1,080($360 x 3 days) copayment for inpatient hospital stay. inpatient 
hospital stay falls within the Inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for inpatient hospital stay provided from April 6, 2021, to April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 21, 2022 to 
March 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you called three different chiropractors 
and none of them were contracted by the Plan. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
chiropractic services. We found no exception that would require the Plan to pay for the chiropractic services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on February 21, 
2022 to March 11, 2022 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of arterial inflow and venous outflow (vascular 
study) (93975) provided on December 8, 2021. You asked the Plan to pay for the vascular study. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the requested vascular study does not meet Medicare criteria for medical 
necessity. 
 
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 pay for the vascular study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation provided for the justification for performance of renal duplex 
scan of arterial inflow and venous outflow (93975). Clinical guidelines do not support carrying out the study in 
this setting. In summary, there is no supportive evidence for the medical necessity of this service in the 
enrollees clinical management. 
 
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 vascular study have not been met. Therefore, we decided that the Plan does 
not have to pay for duplex scan of arterial inflow and venous outflow (vascular study) (93975) provided on 
December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physician services provided on December 
21, 2021, and December 28, 2021. 
 
You asked the Plan to waive the coinsurance for physician services. You say that this provider was never 
approved by you. The Plan denied your request. The Plan says the coinsurance 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance of the total cost for each Medicare covered specialist visit (including surgery second 
opinion, telehealth services, and urgently needed services). 
 
 
 
 The enrollee has been asked to pay $17.91 which is 20% of the allowed amount for physician services. The 
allowed amount is $89.59 (20% x $89.59= $17.91). Physician services fall within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for physician services provided on December 21, 2021, and December 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay and services provided 
from February 1, 2022, to February 7, 2022. 
 You asked the Plan to pay for a SNF stay and services. You say that SNF services were medically necessary. 
The Plan denied your request. The Plan says the enrollee did not meet criteria for SNF services and there are 
insufficient records available to demonstrate a need for the skilled nursing stay. 
 
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 pay for SNF stay and services. Our reviewer says 
that the enrollee did not qualify for skilled nursing facility (SNF) coverage. Our physician reviewer found that 
the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 stay and services have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) stay and services provided from February 1, 2022, to 
February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient visit (99204) provided on March 5, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" is interpreted to mean a 
patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., 
surgical procedure) from the physician or physician group practice (same physician specialty) within the 
previous 3 years. 
 
We looked at the file and Medicare rules. In this case, the records show that the enrollee was seen by the same 
billing provider on December 5, 2021, and December 6, 2021. This means that the enrollee was not considered 
a new patient for the services provided on March 5, 2022. Since the enrollee was not considered a new patient, 
it is inappropriate to bill a new patient visit for these services. Based on this information, we decided that 
Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have 
to pay for the new patient visit (99204) provided on March 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on April 3, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you shouldn't have this charge. 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 $90 
copayment per visit.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall within the Emergency 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 ER visit provided on April 3, 2022.