Persius/hicric huggingface dataset:
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 the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 enrollee appears to be more stable with the current treatment and should only 
require short-term additional acute care hospital services that can safely be provided at the current treatment 
facility until more stable and appropriate for transfer to a lower level of care. There are no services at the 
LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantages. Completion of treatment at the 
current facility is recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 20, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for OON services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the enrollee has no out-of-network benefits. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that 
the Plan does not have to pay for the physician services provided on July 20, 2023, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 18, 2023, to 
May 30, 2023. 
 
You asked the Plan to pay for the inpatient hospital services. You say that this is a foreign medical claim where 
the services were rendered in Mexico. You say that only the billing address is located in Texas. You say that 
the medical records provided support that the claim in dispute should be paid by the Plan, other than any in-network patient cost-share. The Plan denied your request. The Plan says they do not pay providers outside of 
the US directly for emergency services. 
 
The Plan must follow Medicare rules. Medicare rules say that, generally, items and services provided outside of 
the US are not covered. However, the Plan offers a benefit for Worldwide Emergency Services provided 
outside of the US. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file and Medicare rules. The records show that the inpatient services in dispute were provided 
outside of the US. The Plans coverage rules stipulate that when emergency services are provided outside of the 
US, enrollees must pay their bill at the time it is received, and they will be reimbursed for the difference 
between the amount of the bill and their cost-share for the services. The records do not show that the enrollee 
has paid for the services in dispute. The Plans coverage for Worldwide Emergency Services is limited to 
services that have been paid by the enrollee and are reimbursed to that enrollee directly. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital services provided outside of the US on May 18, 2023, 
to May 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorper tablets. 
 
You asked the Plan to pre-approve 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 pre-approve Prochlorper tablets.   
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740 x 2) provided on March 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that crowns are a covered benefit The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 9, 2023. 
Therefore, we decided that the Plan does not have to pay for the crowns (D2740 x 2) provided on March 9, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
25, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 copayment for the ambulance 
services provided on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
February 22, 2023, through February 28, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on February 22, 2023, through February 28, 2023.
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 needs SNF services. 
 The Plan denied your request. The Plan says the enrollee does not meet the requirements for an SNF 
admission. 
 
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 has stabilized medically and is ready for discharge from the hospital. 
The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically 
stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation 
services would be appropriate to improve function, the intermittent skilled services can be provided at a lower 
level of care. The enrollee is medically stable without any acute exacerbations of chronic medical problems. 
The enrollee's physical function is at or near baseline, and she can receive services at a lower level of care. 
Admission to an SNF is not medically necessary. 
 
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: 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 with Parkinsons disease and debilitating 
infection certainly will benefit from a more intensive rehabilitation program with daily medical oversight of the 
multiple comorbidities, physicians and therapy inpatient rehabilitation. 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 patient was 
admitted for wound dehisence of knee incision after a fall. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for dates of service June 13, 2023, to 
June 14, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the professional component was billed for the 
services provided. The Plan denied your request. The Plan says the billed modifier is not applicable to the lab 
services billed. 
 
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 codes 84100, 85027, 83735, 80048, 87186, 87149, 87077, 87040, 84484, 83605, and 81003 
have a status indicator of X. This means that the codes are not payable under the physician fee schedule. 
Although the professional component of a pathology service is payable, the billed codes are not among those 
covered. Based on this information, we decided that Medicare rules for coverage of the billed testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for dates of service 
June 13, 2023, to June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiovascular monitoring services 
provided on August 27, 2023. 
 
You asked the Plan to waive the copayment for cardiovascular monitoring services. You say that this was 
billed for a different day than when you sent the monitor back. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for cardiovascular monitoring services. This item/service falls 
within the 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 copayment for cardiovascular monitoring services provided on August 27, 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 enrollee requires on-going close physician 
management due to high risk of complications. 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. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance services provided on July 26, 2023. 
 
You asked the Plan to pay for the non-emergent services. You say that due to the patient's condition, any other 
means of transport would have been unsafe. The Plan denied your request. The Plan says the services do not 
meet the requirements for approval. 
 
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 services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found the record does not indicate 
that the patient's clinical condition is such that other methods of transport, such as stretcher van, are 
contraindicated or that the expertise, services, and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide was required. 
 
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 services have not been met. Therefore, we decided that the 
Plan does not have to pay for non-emergent ambulance services provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent - per quadrant 
(D4921), and topical application of fluoride varnish (D1206) provided on July 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist was registered in this county and you 
were unaware of that. You also say that you have a denial for $279 stating the provider is out-of-network and 
you know they are in-network. The Plan denied your request. The Plan says these services are not listed among 
the covered dental codes. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigation with a medicinal agent - per quadrant (D4921), and topical application of fluoride varnish (D1206) 
provided on July 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued inpatient hospital admission from June 7, 2022, 
through June 11, 2022.  

You asked the Plan to pay for continued inpatient hospital admission from June 7, 2022, through June 11, 
2022. You say that the services were medically necessary. The Plan denied your request. The Plan says the 
denial is upheld on appeal for delay in discharge. 
 
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 pay for continued inpatient hospital admission from 
June 7, 2022, through June 11, 2022. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the patient was hospitalized but 
discharge was delayed due to insistence on alternative facilitates. Delayed discharge was not medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient hospital admission from June 7, 2022, through June 11, 
2022 have not been met. Therefore, we decided that the Plan does not have to pay for continued inpatient 
hospital admission from June 7, 2022, through June 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E0995 x2, E1002, E1028 x2, E2361, 
E2607, E2620, and K0040). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have medical need for the power tilt option 
included with a K0856 Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with single 
power option (such as code K0856) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has chronic functional loss, uses a manual wheelchair and lives in an 
assisted living facility. The enrollee has had multiple falls. Our reviewer found that the enrollee is dependent on 
facility staff for toileting, and has intact skin. Our physician reviewer also found that the enrollee does not have 
high risk for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of 
managing power drive. 
 
 
 
 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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0955, E0995 x2, 
E1002, E1028 x2, E2361, E2607, E2620, and K0040).