Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an arthroplasty procedure provided on July 
28, 2023. 
 
You asked the Plan to waive the cost share for an arthroplasty procedure. You say that you cannot afford the 
cost share. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities. Your contract with the Plan also clearly says that you must 
pay a $275 copayment for in-network surgery services provided at an outpatient hospital. 
 
 
 You have been asked to pay $540.52 towards the deductible for the arthroplasty procedure. The service you 
asked the Plan to waive the cost share for falls within the outpatient surgery, including services provided at 
hospital outpatient facilities benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to outpatient surgery, including services provided at 
hospital outpatient facilities. This cost sharing is a contractual obligation that had not been met at the time an 
arthroplasty procedure was received on July 28, 2023.  
 
You have also been asked to pay a $275 copayment for the arthroplasty procedure. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities benefit category. You 
have been asked to pay a total of $815.52 ($540.52 deductible + $275 copayment = $815.52). 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 an arthroplasty procedure provided on July 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Medrol. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has a severe allergic reaction to 
Prednisone and needs an oral steroid in addition to topical Ciprodex for the treatment of their condition. 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 Medrol.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care. provided on October 18, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care.. You say that the enrollee was unable to see an 
in-network provider or request an authorization before the services were rendered. 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 subsequent nursing 
facility care. provided on October 18, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation for occupational therapy (OT) and wheelchair 
management services provided on July 28, 2023. 
 You asked the Plan to pay for the evaluation for OT and wheelchair management services. You say that the 
enrollee was no longer on hospice when the services were rendered. 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. 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 July 26, 2023. 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 evaluation for 
occupational therapy (OT) and wheelchair management services provided on July 28, 2023.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the notes do not show that the enrollee's care 
specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; the notes do not show 
that the enrollee has complex care needs that require a coordinated team approach; the notes do not show that 
the enrollee must have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve 
self-care functioning.  
 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 enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care. provided on August 31, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care.. You say that most enrollees require urgent care 
and it is not possible to request authorization before services are rendered. 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 subsequent nursing 
facility care. provided on August 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care provided from June 13, 2023, to 
June 20, 2023. 
 You asked the Plan to pay for inpatient psychiatric care. You say that the treatments administered were 
medically necessary for the enrollee's safety. The Plan denied your request. The Plan says the enrollee could 
have been safely treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer says 
that this inpatient stay does not meet criteria for payment. Our physician reviewer found it was not expected 
that the enrollee would improve in a reasonable period of time beyond the date in question as the enrollee was 
not showing any dangerousness to self or others, auditory or visual hallucinations, or aggressive behaviors 
while not showing any acute threats to safety. It does not appear that active treatment was taking place. It does 
not appear that the services were reasonably expected or medically necessary to improve the enrollees 
condition or for the purpose of diagnosis. The enrollee could have been treated in a less restrictive 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient psychiatric care provided from June 13, 2023, to June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested service is a necessity 
for your care. The Plan denied your request. The Plan says rules for coverage for LDCT have not been met.  
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that you are not between 50 and 77 years of age. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 provided on August 10, 2023. 
 
You asked the Plan to pay for procedure code P9603. 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 supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code P9603 is Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually traveled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the records provided do not 
corroborate traveled miles for the lab services. Based on this information, we decided that Medicare rules for coverage of procedure code P9603 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code P9603 provided on August 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies provided on August 18, 2023. 
 
You asked the Plan to pay for the ambulance supplies. You say that due to your medical condition at the time, 
it was medically necessary to go to the hospital. The Plan denied your request. The Plan says only the 
transportation services are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance supplies provided on August 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on August 17, 
2023. 
 You asked the Plan to pay for the paramedic intercept services. You say that you were transported on the date 
of service. The Plan denied your request. The Plan says the paramedic intercept services do not meet the 
criteria for coverage. 
 
The Plan must follow Medicare rules. 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 under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS provider does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic 
intercept services provided on August 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transport services received July 26, 2023, to 
August 3, 2023. 
 
You asked the Plan to pay for the wheelchair van transport services. You say that the services were medically 
necessary for the enrollee due to their medical condition at the time of transport. The Plan denied your request. 
The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transport services received July 26, 2023, to August 3, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections. 
 
You asked the Plan to pre-approve repeat facet joint injections. You say that the enrollee is in really bad pain 
and been waiting for this procedure and they are trying to get him in as soon as possible. The Plan denied your 
request. The Plan says this does not meet the LCD criteria for approval. 
 
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 repeat facet joint injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the records do not 
indicate that the enrollee had a repeat thermal facet joint injection at the same anatomic site or at least two (2) 
medically reasonable and necessary diagnostic medical branch blocks, with each one providing a consistent 
minimum of 80% sustained relief of primary (index) pain. The review has determined that the enrollee does not 
meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve repeat facet joint injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency treatment and response without transport 
services received on July 4, 2023. 
 
You asked the Plan to pay for the emergency treatment and response without transport services. You say that 
you passed out due to your blood pressure dropping and you don't remember the emergency response crew 
showing up or going to the hospital with you. The Plan denied your request. The Plan says without transport 
there are no payable services. 
 
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 July 4, 2023. 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 emergency treatment and response without 
transport services received on July 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on September 2, 2023. 
 
You asked the Plan to pay for the medication. You say that you are not sure why payment was denied for the 
self-administered drugs you received. 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 pay for the self-administered drugs 
provided on September 2, 2023.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 28, 2022, to 
April 26, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 27, 2022. The NOA was not received by the Plan until June 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from March 28, 2022, to April 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for date of service April 23, 
2022, to May 22, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that a recertification was provided April 25, 2022. However, it was 
not done during the last 5 days of the previous certification period as required. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the home health care billed for date of service April 23, 2022, to May 22, 2022.
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 requires intensive inpatient rehabilitation 
with daily physician management, continuous specialized rehabilitation nursing, and intensive therapies to 
optimize mobility and strengthening while ensuring the restoration of functional status for a safe and 
sustainable discharge. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements 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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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.