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

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided on February 23, 2023, to March 1, 2023. 
 You asked the Plan to pay for IRF care. You say that the services were medically necessary for the enrollee to 
received continued medical management and intensive rehabilitation. The Plan denied your request. The Plan 
says the enrollee did not meet the criteria for IRF services.  
 
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 pay for 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 did not require treatment by multiple therapies. While the medical record 
supported a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care could have been 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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided on February 23, 2023, to 
March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care. provided on June 13, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care.. You say that you are appealing this denial. 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 June 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 8, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 25, 2023, 
through July 28, 2023. 
 
You asked the Plan to pay for the medication. 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 from July 25, 2023, through July 28, 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the air transport services provided on March 16, 2023. 
 
You asked the Plan to pay for the air transport services. You say that the services were medically necessary for 
the enrollee to receive a higher level of care.  The Plan denied your request. The Plan says that the services do 
not meet coverage criteria.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air transport services. Our reviewer says 
that the air transport services were medically necessary. Our physician reviewer found the documentation 
supports that the enrollee suffered from an illness that contraindicated transportation by any other means than 
ambulance. Documentation supports that ground transfer was not safe due to time it would take and need for 
oxygen. Documentation states that the transferring hospital did not have adequate facilities and that transfer 
was for higher 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 the air transport services have been met. Therefore, we decided that the Plan has 
to pay for the air transport services provided on March 16, 2023.  
 
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 the ambulance services provided on September 6, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. 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 the ambulance services provided on September 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative care. provided on July 19, 2023. 
 
You asked the Plan to pay for palliative care.. You say that you are appealing based on medical necessity. 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 palliative care. provided 
on July 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on September 1, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the PT services. You say that that the services should be paid based on a benefit 
exception. The Plan denied your request. The Plan says the services provided should have been from a network 
provider with the Plan and were not urgent or emergent to be provided by an OON 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 
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 physical therapy (PT) services provided on 
September 1, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82105, 82378, 84702, and 86301 provided 
on April 19, 2023. 
 
You asked the Plan to pay for procedure codes 82105, 82378, 84702, and 86301. 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 Alpha-fetoprotein testing, Carcinoembronic 
Antigen testing, Human Chorionic Gonadotropin testing, and Tumor Antigen by Immunoassay CA 19-9 testing 
are coverable when billed with a covered diagnosis code. You billed the Alpha-fetoprotein testing, 
Carcinoembronic Antigen testing, Human Chorionic Gonadotropin testing, and Tumor Antigen by 
Immunoassay CA 19-9 testing with diagnosis codes N83.202, N84.0, and R19.04. Diagnosis codes N83.202, 
N84.0, and R19.04 are not listed in the controlling Medicare policy as covered diagnoses for these services. 
Based on this information, we decided that Medicare rules for coverage of codes 82105, 82378, 84702, and 
86301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 82105, 
82378, 84702, and 86301 provided on April 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on October 04, 2023, to October 
27, 2023. 
 
You asked the Plan to pay for physical therapy. You say that the provider is excellent for what you need. 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 physical therapy 
provided on October 04, 2023, to October 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on  
August 30, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on August 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
October 15, 2023. 
 
You asked the Plan to pay for the ED services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on October 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from MAY 05, 2023, through MAY 11, 2023. 
 
You asked the Plan to pay for the IRF care. You say that the enrollee needed this level of care. The Plan denied 
your request. The Plan says the enrollees medical condition did not require IRF services, and care could have 
been provided in another setting. 
 
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 pay for the 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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from MAY 05, 2023, 
through MAY 11, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve ambulance transportation. 
 
You asked the Plan to pre-approve ambulance transportation. You say that the enrollee cannot safely transverse 
stairs at this time. The Plan denied your request. The Plan says that the documentation does not show that other 
means of transportation are contraindicated, and ambulance transportation is medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transportation. Our reviewer 
says that the service is medically necessary. Our physician reviewer found the records show that this elderly 
enrollee had a periprosthesis fracture above their total knee implant. This fracture makes the enrollee unable to 
walk and is very painful with any mobilization. An ambulance to transport the enrollee to the hospital for care 
is certainly reasonable and medically 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 ambulance transportation have been met. Therefore, we decided that the Plan 
has to pre-approve ambulance transportation.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the arm joint 
before and after contrast. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary.  The Plan 
denied your request. The Plan says the enrollee has not completed six weeks of provider directed treatment.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the medical necessity of the requested MRI of 
the right shoulder has not been established. There are absent appropriate x-rays and a there is no documentation 
of a 6-week course of physical therapy. The MRI cannot be approved 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the arm joint before and after contrast.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport services provided on 
September 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the non-emergent ambulance transport services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says there was no prior authorization requested. 
 
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 
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 non-emergent ambulance transport services 
provided on September 25, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says there is no evidence to support that the least costly material cannot be used. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable.   
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 a crown. Our reviewer says that  Our 
physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the clinical crown lengthening (D4249) and 
prefabricated post and core in addition to crown (D2954) provided on August 9, 2023. 
 
You asked the Plan to pre-approve the clinical crown lengthening and prefabricated post and core. You say that 
the doctor advised that they could not continue crowning the root canal unless the 2 procedures in question 
could be performed. You also say that you needed to keep the tooth and were unaware the procedure was not 
covered. The Plan denied your request. The Plan says these services are not covered expenses under your 
dental plan. The Plan also says that you contacted the Plan prior to the date of service to verify in-network 
providers and you were sent a list of in-network providers. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
clinical crown lengthening (D4249) and prefabricated post and core in addition to crown (D2954) provided on 
August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), provided on August 4, 2023. 
 
You asked the Plan to pay for the office visit. You say that the cost share is wrong. 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 $625 deductible which applies to physician services.  
 
The item or service you asked the Plan to pay for falls within the physician services benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $625 deductible which applies 
to physician services. This cost sharing is a contractual obligation that had not been met at the time the office 
visit was received on August 4, 2023. Therefore, we decided that the Plan does not have to pay for the office 
visit (99214), provided on August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99232 and 99239 billed for dates of service 
January 30, 2023, to February 1, 2023. 
 
You asked the Plan to pay for the billed services. You say that the codes are separate billable charges. The Plan 
denied your request. The Plan says the billed codes 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. 
 
We find that CPT code 99232 and 99239 is not supported in the medical record. The documentation provided 
does not include medical records for dates of service January 31, 2023, and February 1, 2023. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99232 and 99239 billed for dates of service 
January 30, 2023, to February 1, 2023.