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 can tolerate IRF care and would benefit. 
The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 clinical documentation does show that the enrollee has complex functional 
impairments and medical comorbidities; however, therapy notes do not show that the enrollee would tolerate an intensive rehabilitation program or that an intensive rehabilitation program would be medically 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on August 14, 2022. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on August 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
medical records provided support the need for the ambulance transport. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
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 August 21, 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 the ambulance response and treatment with no 
transport provided on August 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission based on medical necessity. The Plan denied your request. The Plan says the request for 
admission to a SNF is denied as 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99220 provided on March 14, 2022. 
 
You asked the Plan to pay for procedure code 99220. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 99220 provided on March 14, 2022, based on Medicare criteria. Therefore, we 
decided that the Plan has to pay for procedure code 99220 provided on March 14, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 14, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were not charged for a 
previous ultrasound and do not understand why you are being charged for this one. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $125 
copayment for Medicare-covered radiological diagnostic services, including an ultrasound.  
 
You have been asked to pay $124.74, which is less than the standard $125 copayment for the ultrasound. This 
item/service falls within the outpatient diagnostic tests and therapeutic 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 ultrasound provided on October 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 10, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
suffering with extremely low blood pressure and 911 was called. You also say that you were unable to 
communicate and don't believe you were able of refusing the transportation. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
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 September 10, 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 the ambulance response and treatment with no 
transport provided on September 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on November 
22, 2022. 
 
You asked the Plan to waive the copayment for a podiatry service. You say that your office visit was very 
short, and you should not have to pay the copayment. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $45 
copayment for podiatry services.  
 
You have been asked to pay a $45 copayment for a podiatry service. This item/service falls within the podiatry 
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 podiatry services provided 
on November 22, 2022.
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 physically weak and cannot walk far 
distances. You say that you need to continue therapy to regain mobility and return to a normal life. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary, and your needs can be let at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have any complex functional deficits or active medical issues. Your 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99214), provided on August 23, 2022. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that they do not have the information they need to consider the charge. 
 
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 has not documented anything wrong with the records provided. 
Therefore, we decided that the Plan has to pay for the office visit (99214), provided on August 23, 2022.  
 
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 reduce the copayment for an inpatient hospital stay provided from 
June 4, 2022, to June 9, 2022. 
 
You asked the Plan to reduce the copayment for hospital stay. You say that you do not know why you are being 
charged for a 10 day stay, instead of 5 days. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $350 
copayment per day, for inpatient hospital care for days 1 to 5.  
 
You have been asked to pay a $350 copayment per day, for days 1 to 5 of inpatient hospital care ($350 
copayment per day x 5 days = $1750). This item/service 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 reduce the copayment for an inpatient hospital stay provided from June 
4, 2022, to June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a walker provided on October 6, 2022. 
 
You asked the Plan to pay for the walker. You say that this should be paid for. The Plan denied your request. 
The Plan says that Healthcare Common Procedure Coding System (HCPCS) code E0143 and E0156 remain not 
supported 
 
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 has not substantiated their denial in this case. The prescription for the 
walker and seat attachment was signed on the same date that the items were provided. The prescription is valid. 
Therefore, we decided that the Plan has to pay for a walker provided on October 6, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 19, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you thought this would 
have a $0 copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $150 copayment for the ambulance services. This item/service falls within 
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 
services provided on October 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee was told by their physician it was 
medically necessary to have rehab for at least 21 days. You say the enrollee has had blood loss, muscle 
deterioration and is a fall risk. The Plan denied your request. The Plan says the SNF services you are requesting 
do not meet the requirements for approval. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. The enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and an x-ray 
provided on October 20, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visit and x-ray. You say that you should 
only be charged one copayment. The Plan denied your request. The Plan says this cost sharing was charged 
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 $45 copayment for each Medicare-covered specialist office visit. Your contract also clearly says that you must pay 
a $45 copayment for each Medicare-covered x-ray.  
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $45 copayment for the x-
ray. You have been asked to pay a total of $90 ($45 copayment + $45 copayment = $90). 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 a specialist office visit and an x-ray provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for End-stage renal disease (ESRD) related services (90960) 
provided on December 31, 2022. 
 
You asked the Plan to pay for End-stage renal disease (ESRD) related services (90960). You say that the 
service should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for End-stage renal disease 
(ESRD) related services (90960) provided on December 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the long-term electroencephalogram (EEG) monitoring provided on 
June 24, 2022. 
 
You asked the Plan to pay for the long-term EEG. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that the service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 long-term EEG. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the patient had known brain infarct, but new symptoms occurred appearing to be epileptic in nature. 
Since the patient resides in an assisted care facility, documentation of seizures for the purpose of medication 
management was necessary. The long-term monitoring was appropriate for management and should be 
covered. 
 
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 long-term EEG have been met. Therefore, we decided that the Plan has to 
pay for the long-term electroencephalogram (EEG) monitoring provided on June 24, 2022.  
 
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.