Persius/hicric huggingface dataset:
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 needs IRF admission for lab and 
medication adjustments. You also say that the enrollee has fluid buildup that needs close monitoring and 
drainage. The Plan denied your request. The Plan says based on the available information, admission to IRF is 
not reasonable and necessary, as the enrollee's condition does not meet the Medicare rules.  
 
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 
was admitted for congestive heart failure, respiratory failure, and bacteremia. 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 and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 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.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided on July 24, 2023.  
 
You asked the Plan to pay for a shower chair. You say that you cannot stand too long in the shower. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair provided on July 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that you need LTACH services. The Plan denied 
your request. The Plan says you are receiving appropriate inpatient acute care and do not require a transfer to 
an LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the criteria for an LTACH admission have not been met. A LTACH transfer is 
not medically reasonable or necessary. You can receiver further care at a lower level of care such as a skilled 
nursing facility (SNF) once you are discharged from the acute care 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
June 16, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you used your best 
efforts to file in a timely manner. The Plan denied your request. The Plan says the time limit for filing has 
expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 The record shows that a claim for the subsequent nursing facility care services was not filed until August 1, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care services 
provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on September 12, 
2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you disagree with 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 physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the physician/practitioner 
services benefit category. You are being asked to pay $125 towards your deductible. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
physician/practitioner services. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on September 12, 2023. Therefore, we decided that the Plan does not have to waive 
the cost share for an office visit provided on September 12, 2023.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to pay an additional amount of $2.43 for the FFR, and an additional $0.59 for the 
CTA. We decided that the Plan does not have to waive the cost share of $140.07 for FFR, and $36.08 for CTA, 
nor pay for the self-administered drug.  
 
You asked the Plan to pay an additional amount of the computed tomographic angiography (CTA) of heart 
(75574), and noninvasive estimated coronary fractional flow reserve (FFR) derived from coronary computed 
tomography angiography data (0503T), and to pay for the self-administered drug (A9270) provided on June 29, 
2023. You say that these services were necessary to help determine why you are experiencing shortness of 
breath. You say that if you had known these tests were not covered, you would have cancelled them. You also 
say that you should not be responsible for this bill. The Plan says that this cost sharing was charged correctly. 
The Plan also says that self-administered drugs are not covered under Medicare Part B. 
 
We decided that the Plan has to pay an additional amount of $2.43 for the FFR, and an additional $0.59 
for the CTA.  
 
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 15% 
coinsurance, a 20% coinsurance for outpatient hospital services. We found that 15% of the allowed amount for 
the FFR ($933.82) is equal to $140.07. We found that 20% of the allowed amount for the CTA ($180.42) is 
equal to 36.08. Therefore, we decided that the Plan has to pay an additional amount of $2.43 for the FFR, and 
an additional $0.59 for the CTA.  
 
We also decided that the Plan does not have to waive the cost share amounts of $140.07 for FFR, and 
$36.08 for CTA, nor pay for the self-administered drug. 
 
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 15% 
coinsurance for simple diagnostic radiology services (the FFR) and a 20% coinsurance for complex diagnostic 
radiology services (CTA). This cost sharing is a contractual obligation you agreed to pay when you enrolled in 
the Plan. Additionally, 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 waive the cost share amounts of $140.07 for FFR, and 
$36.08 for CTA, nor pay for the self-administered drug. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehabilitation is both physically and 
medically necessary in order for the enrollee to return home after hospitalization. The Plan denied your request. 
The Plan says the enrollee does not meet Medicare guidelines for services in 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: 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 are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements 
for approval.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued skilled nursing facility (SNF) stay after 
January 11, 2024.  
 You asked the Plan to pre-approve the continued SNF care. You say that the continued SNF stay is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for the continued SNF stay after January 11, 2024. 
 
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 the continued 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 the enrollee does not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the continued skilled nursing facility (SNF) stay after January 11, 2024.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each wound care service provided on April 
14, 2023, to May 24, 2023. 
 
You asked the Plan to waive the copayment for each wound care service. You say that you find it unfair and 
unreasonable that you have a bigger responsibility for this procedure. 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 $345 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $345 copayment for each wound care service. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
The total you owe is $2,070 ($345 copayment x 6 visits = $2,070). Therefore, we decided that the Plan does not 
have to waive the copayment for each wound care service provided on April 14, 2023, to May 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient detoxification. 
 You asked the Plan to pre-approve inpatient detoxification. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request for an inpatient detoxification level of care is not medically 
necessary. The enrollee does not appear to have complex medical factors that would require prolonged workup 
and treatment in the hospital to support a reasonable expectation that the enrollee would require medically 
necessary hospital care that crosses two midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient detoxification. Our reviewer 
says that the requested inpatient detoxification services are not medically reasonable and necessary. Our 
physician reviewer found the enrollee has an alcohol use disorder and methamphetamine use. The enrollee is 
documented as not having suicidal or homicidal ideation. The documentation provided does not support 
complex medical factors that would require prolonged workup and treatment. 
 
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 detoxification have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient detoxification.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from August 1, 
2023, through August 17, 2023. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you do not agree with the billed 
amount for the services you received. 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 for each admission you 
must pay $20 per day for days 1-20 of a benefit period, and $0 per day for days 21-100 of a benefit period. 
  You have been asked to pay a total of $340 for the SNF stay. This item/service falls within the skilled nursing 
facility (SNF) care benefit category. The total copayment you owe is $340 ($20 copayment x 17 days = $340). 
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 copayment for the SNF stay provided from August 1, 2023, through August 
17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the laboratory services provided on 
September 28, 2023. 
 
You asked the Plan to waive the cost share for the lab services. You say that you were told that the service 
would be fully covered. 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 $150 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also clearly says that you must pay 10% 
coinsurance for the diagnostic services, after you meet your deductible. 
 
 
 You have been asked to pay $150, which satisfied the deductible for the lab services. The remaining allowed 
amount is $610 ($760 allowed amount - $150 deductible = $610). The services you asked the Plan to waive the 
cost share for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which 
applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual 
obligation that had not been met at the time the lab services was received on September 28, 2023.  
 
You have also been asked to pay $61, which is 10% coinsurance of the remaining allowed amount for the lab 
services. This service falls within the durable medical equipment and related supplies benefit category. You 
have been asked to pay a total of $211 ($150 deductible + $61 coinsurance = $211). This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for the laboratory services provided on September 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service August 31, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the diagnosis codes are accurate. The Plan denied 
your request. The Plan says an appropriate primary diagnosis code was not billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99214 was billed with secondary diagnosis code Z01.818, defined as encounter for 
other preprocedural examination. Diagnosis codes for routine examinations should be billed as the primary 
diagnosis. Based on this information, we decided that Medicare rules for coverage of the billed service have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99214 billed for date of 
service August 31, 2023.