Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 18, 2021, 
to July 19, 2021. 
 
  You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee was provided with 
medically necessary services, and payment was expected for the services rendered. The Plan denied your 
request. The Plan says the information now received does not support that criteria were met for inpatient 
hospitalization. The Plan also says that evaluation, treatment, and monitoring in a lower level of care, such as 
observation, may have been an option. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee presented to the emergency department with migraine 
headache and facial numbness on the left with dizziness. Our reviewer found that a computed tomography scan 
of the head showed no acute findings, atrial fibrillation was diagnosed via electrocardiogram with normal rate, 
there was bilateral nystagmus found on exam resolved quickly. Our physician reviewer also found that 
cerebrovascular accident was ruled out, and vitals and other workup showed the enrollee was stable and did not 
require hospital services that would likely cross 2 midnights for continued workup as the case had low 
complexity and low severity.  
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from July 18, 2021, to July 19, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you shouldnt have to pay for this. 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 $195 
copayment for Diagnostic radiology services. 
 
You have been asked to pay a $195 copayment for CT scan. This item/service falls within the Diagnostic 
radiology 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.You have been asked to pay a $144.12 copayment which is less than the standard $195 copayment 
for CT scans. Therefore, we decided that the Plan does not have to waive the copayment for CT scan provided 
on July 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on July 21, 
2022. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you didnt think it would cost 
this much or you wouldnt have had the surgery. 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 10% 
coinsurance for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay 10% coinsurance for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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.You have been asked to pay $899.45 which is 10% of the allowed 
amount for the outpatient surgery. Therefore, we decided that the Plan does not have to waive the coinsurance 
for outpatient surgery provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 16, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on September 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and closed treatment of distal radial 
fracture or epiphyseal separation (25600) provided on March 29, 2022. 
 
You asked the Plan to pay for the physician services. You say that this should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit (99204) and closed treatment of distal radial 
fracture or epiphyseal separation (25600) provided on March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging provided on May 20, 2022. 
 
You asked the Plan to pay for diagnostic imaging. You say that you submitted a corrected claim with a 
different current procedural terminology (CPT) code. You say that you would like the claim to be reviewed, 
reprocessed and paid. 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 diagnostic imaging 
provided on May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on June 
06, 2022. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you were not charged 
for the injections before. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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.The allowed amount for the injection is $1,275.60, and the 20% coinsurance 
applied per the EOC is $255.12. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the denosumab injection provided on June 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit, 30 minutes, (90832) provided on 
March 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the service was rendered to the enrollee 
in good faith. The Plan denied your request. The Plan says prior authorization was not 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy visit, 30 minutes, (90832) provided on March 
1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office or other outpatient visit for the evaluation and management 
of a new patient (99204) provided on October 7, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that this should be covered. The 
Plan denied your request. The Plan says that the enrollee has received face-to-face services by this provider or 
another provider of the same specialty and sub-specialty who belongs to the same group practice within the 
past three years. 
 
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. Specifically, the file does not support that the enrollee has seen another provider 
with the same specialty within the last three years. Therefore, we decided that the Plan has to pay for the office 
or other outpatient visit for the evaluation and management of a new patient (99204) provided on October 7, 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested treatment is medically 
necessary. The Plan denied your request. The Plan says the request for approval of proton radiation therapy is 
denied as not medically necessary. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based upon the provided records, it is not plausible that proton therapy would provide 
a clinically meaningful benefit over a well-designed IMRT plan. While not experimental, its potential benefit 
over non-proton-based radiation is an investigational question. Thus, proton therapy is not necessary as it 
would not meet ASTRO or NCCN criteria and therefore would not be furnished in accordance with accepted 
standards of medical practice. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment at an opioid treatment program 
provided on June 20, 2022. 
 
You asked the Plan to pay for medication assisted treatment at an opioid treatment program. You say that the 
facility does not require patients do not make appointments or get referrals from their primary physician when 
they decide to seek addiction treatment. 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 medication assisted 
treatment at an opioid treatment program provided on June 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on February 22, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right lower back injection. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation indicates that the right L3-L4 radiofrequency ablation resulted in near complete resolution of the enrollee's low back pain. The review has determined that the enrollee does not 
have a diagnosis/condition that meets criteria for the requested right facet joint injection. The requested 
services are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right lower back injection.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on 
April 14, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee was no longer enrolled in 
hospice on the date of service in this case. The Plan denied your request. The Plan says the enrollees claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 12, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing facility care (99310) provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve headgear for a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve these services. You say that the headgear wears out every three months. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that one headgear coded A7035 is covered every six 
months. 
 
We looked at the file and Medicare rules. The requested headgear replacement is covered only once every six 
months. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve headgear for a continuous positive 
airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro2 Motion G orthotic device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says although the requested device is reported as having some utility in post-stroke 
rehabilitation in terms of facilitating recovery, it is not considered the standard of care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the current clinical guidelines designate robotic therapy to be of "uncertain utility compared with 
dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro2 Motion G orthotic device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the lntracept procedure meets all of the criterion used to evaluate whether or not a 
device is 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on January 22, 2022. 
 
You asked the Plan to pay for air ambulance services. You say that this was medically necessary. The Plan 
denied your request. The Plan says you were not transported to the nearest appropriate facility. 
 
The Plan must follow Medicare rules. Medicare rules say that an ambulance transport is covered to the nearest 
appropriate facility to obtain necessary diagnostic and/or therapeutic services as well as the return transport. 
 
We looked at the file and Medicare rules. The submitted documentation shows that the transport at issue was 
not to the nearest appropriate facility for diagnostic or therapeutic services. Based on this information, we 
decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for air ambulance services provided on January 22, 2022.