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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that minimal therapy at a skilled nursing level will not be 
enough to ensure to be able to return home to previous level. The Plan denied your request. The Plan says that 
the enrollee does not meet the requirements. Services needed may be provided safely in 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found there is every reason to expect that the enrollee will participate in and benefit from services, an inpatient 
rehabilitation facility approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 12, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee's hospice ended on May 10, 
2023. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 ambulance services provided on May 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 23, 2023. 
 You asked the Plan to pay for the ambulance transport service and ground mileage. You say that the medical 
records support the medical necessity for transport. The Plan denied your request. The Plan says a physician's 
office is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on January 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you do not agree with the denial of services. 
The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The enrollee has been approved with an in-
network provider for dates of service May 5, 2023, to December 31, 2023. We found no exception that would 
require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-
approve physical therapy to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for injections and outpatient surgery on 
February 02, 2023, to February 23, 2023.  
 
You asked the Plan to waive the cost share for injections and outpatient surgery. You say that you want to 
appeal the amount being charged. 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 20% 
coinsurance for each Medicare-covered Part B drug obtained in a providers office or outpatient setting. 
Covered drugs include drugs that usually arent self-administered by the patient and are injected or infused 
while you are getting physician, hospital outpatient, or ambulatory surgical center services. You must pay a 
$325 for each Medicare-covered outpatient hospital facility visit. The provider billed in the amount of $381 and 
the allowed amount is $198.44 for the services. $198.44 x 20% = $39.69. There were four services done. 
$39.69 x 4 = $158.76. The provider billed in the amount of $1,266 and the allowed amount is $176.07 for the 
service. $176.07 x 20% = $35.21. The provider also billed in the amount of $960 and the allowed amount is 
$319.53. This is less than the copayment amount. For all services it's, $158.76 + $35.21 + $319.53 = $513.50. 
Therefore, results in the total cost sharing amount of $513.50. 
 
You have been asked to pay a 20% coinsurance for injections and $319.53 copayment, which is less than the 
copayment for outpatient surgery. This item/service falls within the Medicare Part B prescription drugs and 
outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for injections and outpatient surgery 
on February 02, 2023, to February 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for virtual care services provided on August 11, 2022. 
 
You asked the Plan to pay for virtual care services. You say that per the medical records, these service are 
covered under the patient's benefit plan and are necessary for the patient. The Plan denied your request. The 
Plan says per the member's Evidence of Coverage, no benefit coverage is available for virtual services 
performed by an out-of-network provider.  
 
The Plan contract says that virtual care (also referred to as telehealth services, virtual check-ins or eVisits) is 
not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that virtual care (also referred to as telehealth 
services, virtual check-ins or eVisits) is not covered out-of-network. Based on this information, we decided that 
the Plans rules for coverage of virtual care services have not been met. Therefore, we decided that the Plan 
does not have to pay for virtual care services provided on August 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esbriet. 
 
You asked the Plan to pre-approve the medication. You say that you would like reconsideration of this denial. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esbriet.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 services are medically necessary for the enrollee 
to work at improving mobility and their overall health in a facility familiar with stroke rehabilitation. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on October 19, 
2022. 
 You asked the Plan to pay for the paramedic intercept services. You say that you do not believe you should be 
held responsible for the charges for this service. The Plan denied your request. The Plan says no payment can 
be made as paramedic intercept is not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on October 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0429 and A0425) provided on 
February 8, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file, the claim, and Medicare rules. The claim shows that external cause code, W01.0XXA, was billed as the principal or first-listed diagnosis code incorrectly. Therefore, we decided that the Plan does 
not have to pay for the ambulance services (A0429 and A0425) provided on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you need this item. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve the physician services. You say that you have received pain injections from 
the requested provider in the past. You say that your primary care physician recommended this provider. The 
Plan denied your request. The Plan says there are network providers available to provide these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the colonoscopy and the Part B drugs 
provided on February 15, 2023. 
 
You asked the Plan to waive the cost share for the colonoscopy and the drugs. You say that you should not 
have a 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 per visit, for outpatient surgery or procedure at an outpatient hospital facility. Your contract with 
the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B covered drugs. 
 
You have been asked to pay $120.09, which is less than the standard copayment for the colonoscopy. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
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 also been asked to pay $0.78, which is 20% coinsurance of the allowed amount for the drugs ($3.91 
allowed amount X 20% =$0.78). You have been asked to pay a total of $120.87 ($120.09 copayment + $0.78 
coinsurance = $120.87). This item/service falls within 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. Therefore, we decided that 
the Plan does not have to waive the cost share for the colonoscopy and the Part B drugs provided on February 
15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose and the enrollee's needs could 
be met by a bilevel positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scooter rental provided on July 7, 2022. 
 
You asked the Plan to pay for the scooter rental. You say that you feel this should be covered because you were 
advised it would be covered and needed this item after your knee surgery. The Plan denied your request. The 
Plan says according to the call the Plan made to the provider, they stated they are a mobility rental scooter 
company on the Jersey Shore, and you rented the scooter to get around while at the shore. The Plan also says 
the scooter rental denied correctly as non-covered in accordance with your benefits. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the scooter rental provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee does not 
meet the guidelines. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Euflexxa. Our physician reviewer found 
that the enrollee has a history of chronic left knee pain due to osteoarthritis of the knee. She has been treated 
with medication, corticosteroid injections, and viscosupplementation therapy. In this case, there is insufficient 
evidence of significant improvement in pain and functional capacity from the prior injection. The review has 
determined that the requested injection is not indicated for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 provided on November 30, 2022. 
 
You asked the Plan to pay for procedure code 99223. 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 99223 based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for procedure code 99223 provided on November 30, 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's comorbidities require ongoing medical 
management and an intensive multidisciplinary therapy program. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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.