Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve aquatic therapy. You say that the suggested provider for therapy doesn't 
have access to a pool. You say that the clinical documentation supports the need for aquatic therapy. The Plan 
denied your request. The Plan says aquatic therapy is not medically necessary. 
 
Aquatic therapy may be considered reasonable and necessary in the treatment of specific conditions. 
 
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 aquatic therapy. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found that the enrollee does not have 
rheumatoid arthritis, fibromyalgia, paraparesis, hemiparesis, a recent amputation, recovery from a paralytic 
condition or recent head trauma. Our reviewer says that there is no evidence that the enrollee has the inability 
to tolerate exercise for rehabilitation under gravity-based weight bearing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve aquatic therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (0047U) provided on January 13, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that the service provided was medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 laboratory service (0047U) provided on 
January 13, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve autologous bone marrow transplant. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not 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 services. Our physician reviewer 
found the extent of organ involvement is considered as predictor of outcome. The best outcomes following 
SCT have been reported in patients who achieve complete response (CR) to high-dose primary chemotherapy 
including improvement in organ related disease. The decision on transplant eligibility should be made based on 
a risk-benefit assessment and the needs and wishes of the patient on not strictly on guidelines. Should you have 
a good response to current treatment an autologous transplant would be reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve autologous bone marrow transplant.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310) with an endodontist. 
 
You asked the Plan to pre-approve the dental service. You say that you have a tooth with a deep cavity. You 
also say that you need to have a root canal done. The Plan denied your request. The Plan says services must be 
performed by a participating general dentist to be covered. The Plan also says that dental services from an 
endodontist are not covered. 
 
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 items or services are not 
among those covered under this benefit when you receive them by an endodontist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation (D9310) with an endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit and radiology 
services and coinsurance for an injection provided by a participating provider on February 5, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit and radiology services and coinsurance 
for an injection. You say that you do not feel like you should be held financially responsible for this. The Plan 
denied your request. The Plan says the correct copayments and coinsurance has been applied. 
 
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 $40 
copayment for physician/practitioner services/specialist, a $50 copayment for outpatient diagnostic 
tests/diagnostic procedures and tests and a 20% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $40 copayment for a specialist office visit, a $50 copayment for radiology 
services and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $53.90. 
The amount you owe for an injection is $10.78 ($53.90 x 20% = $10.78). The total amount you are being asked 
to pay is $100.78 ($40 + $50 + $10.78 = $100.78).  
 
A specialist office visit falls within the physician/practitioner services/specialist benefit category. Radiology 
services falls within the outpatient diagnostic tests/diagnostic procedures and tests benefit category. An 
injection falls within the Medicare Part B prescription drugs 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 a specialist office visit and radiology services and coinsurance for an injection 
provided by a participating provider on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device (CPT Code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (CPT Code 
22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of 
rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at 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 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network home health provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the provider is not participating.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network home health provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating facility on January 23, 2020, to January 29, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you have never been 
charged this much for these services before. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
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 $225 
copayment for outpatient surgery/services provided to you at a hospital.  
 
You have been asked to pay $165.45 which is less than your copayment amount of $225 for outpatient hospital 
services. The total amount you are being asked to pay is $1,158.15 ($165.45 x 7 visits = $1,158.15). Outpatient 
hospital services falls within the outpatient surgery/services provided to you at a hospital 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 outpatient hospital services provided by a participating 
provider on January 23, 2020, to January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara to be provided by the requested out-of-network 
provider. 
 
You asked the Plan to pre-approve Stelara to be provided by the requested out-of-network provider. The Plan 
denied your request. The Plan says there are in-network providers available to provide this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve Stelara to 
be provided by the requested out-of-network provider.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found the member does not require skilled nursing 
and/or skilled therapy services on a daily basis.  The member is medically stable and can receive further rehab 
services at a lower level of care. Although further rehab services would be appropriate to improve function, as 
a practical matter, the daily skilled services can be provided at a lower level of care than a skilled nursing 
facility. The member does not have any parental medication; complex wound care or nutrition given via a 
feeding tube. The member is medically stable without any acute exacerbations of chronic medical problems. 
The member's physical function is at or near their baseline and he can receive services at a lower level of care. 
Admission to a SNF for inpatient skilled rehab services 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services 
with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 
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 skilled nursing facility (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 will benefit from 24 hour nursing care, 
regular physician rounding and intense physical therapy and occupational therapy to build up strength and 
endurance. You say that IRF care is expected to prevent the onset of an illness, condition or disability. You say 
that IRF care will assist the enrollee to achieve maximum functional capacity in performing daily activities. 
The Plan denied your request. The Plan says the records do not show a need for evaluations by a rehab doctor 
or a need to take part 3 hours daily for 5 days a week. The Plan says that the enrollee can safely receive the 
services needed 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 above. 
 
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 vascular surgery for occluded artery in the right leg. Medical problems are stable. There are 
no identified problems that need inpatient medical management. 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. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. 
 
 
 
 
 
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 a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is in desperate need for 
therapy. The Plan denied your request. The Plan says the SNF level of care is not medically necessary for the 
enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 SNF admission. Our reviewer says 
that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did 
not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a SNF admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten extractions. 
 
You asked the Plan to pre-approve the extractions. You say that all of your teeth have to be extracted and 
replaced with dentures. The Plan denied your request. The Plan says the benefit limit has been exhausted for 
the 2020 plan year. 
 
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. The Plan covers ten 
extractions per year. 
 
The file shows two extractions were already approved for the year. Based on this information, we decided that 
the Plan's rules for coverage of the extractions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ten extractions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee and billed under codes 
80157, 80177, 80201, 80162, 80159 and 80173 for the date of service May 18, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the physician order was incomplete and the specimen type collected is incorrect for the 
billed codes; therefore, the code cannot be verified. The Plan states these tests are performed on a blood 
specimen collected by venipuncture. The submitted toxicology request form indicates the specimen was urine. 
It is noted multiple attempts were made to obtain additional information from the provider 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provided medical records to support the services 
billed. In this case, the claim submitted cannot be paid due to inconsistent information provided regarding the 
physician order and the type of specimen collected. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services provided to the enrollee and billed under codes 80157, 80177, 80201, 80162, 80159 and 80173 for 
the date of service May 18, 2020.