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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's ongoing medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by Health Plan. Documentation does not support that LTACH services are appropriate at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for emergency room services, inpatient hospital 
stay, and x-rays on August 03, 2022, to September 03, 2022.  
 You asked the Plan to waive the cost share for ER, inpatient hospital stay, and x-rays. 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 $65 
copayment for each emergency room visit. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. 
You must pay a $500 copayment for each Medicare-covered hospital stay each time you are admitted. Includes 
inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. 
Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. The 
day before you are discharged is your last inpatient day. You must pay a 5% coinsurance for each Medicare-
covered standard X-ray service. Covered services include but are not limited to X-rays (when the service is 
performed at a hospital, outpatient facility or a freestanding facility imaging or diagnostic center). The provider 
billed in the amount of $486.86 and the allowed amount is $80.39 for the service. $80.39 x 5% = $4.02. For the 
services it's, $65 + $500 + $4.02 = $569.02. Therefore, results in the total cost sharing amount of $569.02. 
 
You have been asked to pay a $65 copayment for ER, a $500 copayment for inpatient hospital stay, and a 5% 
coinsurance for x-rays. This item/service falls within the emergency care, impatient hospital care and outpatient 
diagnostic tests and therapeutic services and supplies 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 emergency room services, inpatient hospital stay, and x-rays on August 03, 2022, to September 
03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 24, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on February 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 inpatient rehabilitation an appropriate destination to 
be discharged to which will furnish appropriate care, meet your medical needs, and treat current condition. The 
Plan denied your request. The Plan says your records do not show that you need an intensive team for your 
care. 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does 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 inpatient rehabilitation facility (IRF) admission and services.
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 necessary for rehabilitation to 
maximize the enrollee's potential to return to their previous level of independence. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare 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 pre-approve a total hip arthroplasty (27130) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that you are in a great amount of pain, and 
you feel that it is worsening with time. The Plan denied your request. The Plan says you are requesting for this 
service to be rendered by an OON provider. The Plan also says the service is not emergent/urgent and is 
available within the Plan's network. 
 
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. 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 
a total hip arthroplasty (27130) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for each physical therapy service provided on October 05, 2022, 
to October 19, 2022. 
 
You asked the Plan to pay for each physical therapy service. You say that the enrollee was referred for this 
service. 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 each physical therapy 
service provided on October 05, 2022, to October 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve massage therapy services. You say that you would like this service appealed 
as this is beneficial to your health and your back. You also say that your doctor recommends this for you to 
have. The Plan denied your request. The Plan says Medicare does not cover massage therapy. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 21, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 home visit provided on 
February 21, 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 the services are medically necessary for the enrollee 
to continue therapy services for strengthening endurance and mobility to ensure a safe discharge. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the computed tomography (CT) scan of the abdomen, pelvis and 
chest. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary to see the 
cause of your weight loss. The Plan denied your request. The Plan says that the medical records do not show 
why you need this or what your doctor will be looking for with this test.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the CT scan. Our reviewer says that the 
CT scan is medically necessary. Our physician reviewer found the request for a CT scan of the chest, abdomen 
and pelvis is reasonable based upon the history including multiple sclerosis (MS). Prior to assuming the weight 
loss is attributable to your MS, other causes including occult malignancy need to be excluded.  You do not have 
a significant smoking history as well.  The request should be 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 the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the computed tomography (CT) scan of the abdomen, pelvis and chest.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement procedure provided on April 25, 2023. 
 
You asked the Plan to pay for a debridement procedure. You say that you are requesting reconsideration of the 
denied claim. 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 debridement procedure 
provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on March 07, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that these services were medically 
necessary. 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 an office visit, and 
related services provided on March 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 12, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says enrollees must receive their care from a 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 lab services provided on April 12, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on January 31, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that the enrollee has been in a 
facility. 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 chronic care 
management services provided on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 10, 
2023. 
 You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 92933. 
 
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, we have confirmed that code 93010 
is a column II code to column I code 92933. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service February 10, 
2023.