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

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing care needs.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care. provided on June 09, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care.. You say that the facility is responsible for 
obtaining authorization. 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 09, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on September 1, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the transport method was medically 
necessary. The Plan denied your request. The Plan says the enrollee was not transported to the closest facility. 
 
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 ambulance services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found there were two other hospitals 
were closer and capable of caring for patient. His medical issue did not seem to be a complication of his 
transplant and he did not require continuity of care with his transplanting institution. 
 
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 ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on September 1, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2023. 
 You asked the Plan to pay for the laboratory services. You say that the enrollee was not on hospice on the date 
of service. 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 September 1, 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 laboratory 
services provided on September 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on September 28, 2023, to October 1, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the enrollee was talked out of going to the hospital by the ambulance crew and on October 2, 2023, the enrollee 
was transported to the hospital and admitted. 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 September 28, 2023, to October 1, 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 ambulance response 
and treatment without transport services received on September 28, 2023, to October 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on August 4, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the bill should be covered. 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 August 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 ambulance response and treatment without 
transport services received on August 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the leg joint. 
 
You asked the Plan to pre-approve the MRI of the leg joint. You say that the MRI is medically necessary. The 
Plan denied your request. The Plan says there are no results of x-rays to show a need for further imaging. 
 
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 of the leg joint. Our reviewer 
says that the MRI is not medically necessary. Our physician reviewer found the enrollee has left hip and low 
back pain. There are no plain films of the left hip that are in the records to establish the medical necessity of the 
requested MRI left hip. The services cannot be approved based on the documentation received. 
 
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 of the leg joint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the leg joint.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound and electrocardiogram services provided on 
August 13, 2023, to August 15, 2023. 
 You asked the Plan to pay for the ultrasound and electrocardiogram services. You say that the enrollee was not 
on hospice at the time of services. 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 August 14, 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 ultrasound and 
electrocardiogram services provided on August 13, 2023, to August 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan Tablet. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. 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 Xifaxan Tablet.   
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: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services provided on September 
15, 2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not 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 pay for the non-emergent transport services. Our 
reviewer says that the non-emergent transport services were not medically necessary. Our physician reviewer 
found the enrollee was not bedridden, as evidence by their ability to walk. The enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering the enrollees 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 the non-emergent transport services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent transport services provided on September 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services provided on April 3, 
2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says transport to a doctors office is not a covered benefit. 
 
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 the non-emergent transport services provided on 
April 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional physical therapy (PT) services to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the additional OON PT services. You say that the previously referred in-
network provider had a negative outcome for the PT services received and you had a better experience with the 
OON provider. The Plan denied your request. The Plan says the OON provider is not medically necessary for 
the PT services as there are other in-network Plan providers that can be used. 
 
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 
the additional physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services provided on June 28, 
2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the services were medically 
necessary for the enrollee to safely transport to their appointment. 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 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 the non-emergent transport services provided on 
June 28, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from August 14, 2023, to August 15, 
2023. 
 
You asked the Plan to pay for inpatient hospital care. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the admitting physician clearly saw this as related to the first 
hospital stay with discharge on August 6, 2023; therefore, this is a readmission. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 hospital care. Our reviewer says 
that this inpatient stay meets criteria for payment. Our physician reviewer found the enrollee had an acute 
syncopal episode and was brought to this hospitals emergency department. The enrollee was found to be in a 
state of volume contraction with orthostatic hypotension. The enrollee was given fluid replacement and home 
diuretic dosage was stopped. The enrollee was eventually discharged home with half the previous dosage of 
loop diuretic. At the time of discharge from the previous hospitalization the enrollee was hemodynamically 
stable. This admission was medically necessary and not the result of a premature discharge from the same 
hospital.  
 
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 hospital care have been met. Therefore, we decided that the Plan has to 
pay for inpatient hospital care provided from August 14, 2023, to August 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an LDCT scan for lung cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee meets United States 
Preventive Services Task Force (USPSTF) criteria for an LDCT scan. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for an LDCT scan. 
 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 the enrollee is not between 55 to 77 years of age. 
Therefore, we decided that the Plan does not have to pre-approve an LDCT scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a VivAer procedure. 
 
You asked the Plan to pre-approve a VivAer procedure. You say that the Plan is required to cover anything that 
Original Medicare covers. You say that Original Medicare covers nasal airway remodeling using the codes that 
have been requested. The Plan denied your request. The Plan says the procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a VivAer procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates the enrollee has nasal obstruction and inferior turbinate 
hypertrophy. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollees specific conditions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a VivAer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 1, 2023. 
 
You asked the Plan to pay for the naturopath service. You say that this has been your regular doctor who you 
see for all of your regular preventive care. You say that your visits usually fit into the allowed naturopath visits 
per year. You also say that you have had more health issues than normal this year. The Plan denied your 
request. The Plan says the benefit for these services has been exhausted. 
 
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for the 
services of a naturopath only for 6 visits every calendar year.  
 
The file shows that the Plan has paid for 6 visits with the naturopathic provider. Therefore, we decided that the 
Plan does not have to pay for the office visit provided on August 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 8, 
2023. 
 
You asked the Plan to pay for the billed code. The Plan denied your request. The Plan says the code cannot be 
billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 83789 billed for date of service August 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient care provided from June 20, 2023, to 
July 19, 2023. 
 
You asked the Plan to pay for the continued inpatient care. You say that you would like all the documents to be 
reviewed for a first level appeal. The Plan denied your request. The Plan says the continued acute inpatient care 
was not medically necessary. 
 
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 the continued inpatient care. Our reviewer 
says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our 
physician reviewer found it was not expected this patient would improve in a reasonable period of time for the 
dates in question as they did not have suicidal or homicidal ideation, auditory or visual hallucinations. The 
patient was compliant with treatment while not showing any acute threats to safety. Our reviewer also found 
that it did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower 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 continued inpatient care have not been met. Therefore, we decided that the 
Plan does not have to pay for the continued inpatient care provided from June 20, 2023, to July 19, 2023.