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

 
We decided that the Plan does not have to pay for the emergency department visit provided on February 14, 
2020. 
 
You asked the Plan to pay for the emergency department visit (99285). You say that the claim should be paid at 
the 99285 level. The Plan denied your request. The Plan says the level of service was reduced to 99284 based 
on the diagnostic information on the claim. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 emergency department visit (99285). Our 
reviewer says that that ER services code 99285 was not met. Our reviewer found in this case medical decision 
making of high complexity was not documented. The review has determined that the services were not 
provided at the level of high severity and pose an immediate significant threat to life or physiologic function 
 
 
(99285). The services provided were at the level of high severity but not posing an immediate significant threat 
to life or physiologic function (99284). 
 
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 emergency department visit (99285). have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for continued care with a tertiary-level 
urologist. 
 
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 enrollee is approved to see a network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 referral. Our reviewer says that the 
requested referral is not medically reasonable or necessary. Our physician reviewer found there is no medical 
necessity to continue care with the same tertiary care level provider. A non-tertiary level provider is available. 
There is no medical necessity for the highly specialized/technical tertiary level of care. Routine urological care 
in a non-tertiary care setting for follow-up is adequate. 

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 referral. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for continued care with a tertiary-level urologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal for tooth #31. 
 
You asked the Plan to pre-approve a root canal. You say that you cannot afford the services. The Plan denied 
your request. The Plan says the requested treatment for molars is 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.  
 
We looked at the file, and Medicare rules. A root canal on the requested tooth is not covered by your plan. 
Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a root canal for tooth #31.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve enteral formula for oral intake for the enrollee. 
 
You asked the Plan to pre-approve the formula. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 formula. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is clearly malnourished and has chronic conditions that impair ability to take in adequate 
nutrition. It is reasonable to try high calorie supplementation given documented malnutrition. 
 
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 formula have been met. Therefore, we decided that the Plan has to pre-
approve enteral formula for oral intake for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a new patient visit (99204) provided June 17, 2020. 
 
You asked the Plan to pay for the new patient visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was provided to support the service 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 code 99204 is not supported in the medical record. Specifically, the records provided do not 
show that the rendering provider was of a different specialty than the rendering provider that performed a new 
patient visit previously within the past 3 years. The plan requested additional documentation and it was not 
received. Based on this information, we decided that Medicare rules for coverage of the new patient visit have 
not been met. Therefore, we decided that the Plan does not have to pay for a new patient visit (99204) provided 
June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient assisted living visit provided on May 21, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the new patient assisted living visit. You say that the service provided was 
medically necessity. 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 new patient assisted living visit provided on 
May 21, 2020, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission into a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission into a SNF. You say that you need SNF care. The Plan denied 
your request. The Plan says rules for SNF care have 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 admission into a SNF. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require 
skilled nursing or therapy services on a daily basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission into a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission into a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a skilled nursing facility or any other 
lower level of care is not adequate for the enrollee. The Plan denied your request. The Plan says rules for 
LTACH care have not been met. 
 
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 the 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 transfer to a LTACH is not medically necessary at this time. The enrollee is 
receiving appropriate care at the current acute care facility. The review has determined that the enrollee does 
not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee nor able to be furnished 
safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomographic angiography (CTA) scan of 
the chest (71275). 
 
You asked the Plan to pre-approve the CTA scan of the chest. You say that a CTA scan of the chest is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of a CTA scan of the chest. 
 
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 CTA scan of the chest. Our reviewer 
says that a computed tomographic angiography scan of the chest is not medically necessary. Our physician 
reviewer found that a CTA scan of the chest is not indicated to follow progress of a treated pulmonary embolus 
in an asymptomatic patient. It would be different if it were felt that the patient was at risk for having recurrent 
pulmonary emboli. The patient is on anticoagulation and has no symptoms. Therefore, there is no indication for 
this test.  
 
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 CTA scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the computed tomographic angiography (CTA) scan of the chest (71275).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires close daily oversight. The Plan 
denied your request. The Plan says the enrollee does not need close supervision by a rehab doctor, or a multi-
team approach to rehab. 
 
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 physician reviewer found 
that the enrollee is at a standby assist level for ambulation using a four-wheeled walker and toileting. She is at a 
contact guard assist level for bed to chair transfers, independent for lower body dressing, and moderate 
independent for bed mobility. The complexity of her nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Her medical status 
does not currently require intensive physician and nursing oversight only in an IRF. She may benefit from 
multiple therapies, such as physical and occupational therapy, but the documentation does not support that her 
functional status requires or can tolerate an 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray services (71046, Q0092, R0070) provided on 
December 4, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the X-ray services. You say that you did not have enough time to verify 
eligibility. 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 X-ray services (71046, Q0092, R0070) 
provided on December 4, 2019, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you need these services 
because of anxiety and depression. The Plan denied your request. The Plan says that you have no acute 
symptoms that require you to be transferred to 24 hour inpatient psychiatric care. 
 
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 pre-approve inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary in this 
case. It is not expected you would improve in a reasonable period of time as you do not have dangerousness to 
self or others, auditory or visual hallucinations or behaviors threatening acute safety. You do not require 
inpatient mental health treatment as you are not a danger to yourself or others and are cooperative with care 
without any aggressive behaviors. Our physician reviewer found that your condition does not meet Medicare 
criteria for inpatient psychiatric hospital services. 
 
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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ondansetron hydrochloride injection (J2405), unclassified 
drugs (J3490) and infusion (96360) provided on June 12, 2020. 
 
You asked the Plan to pay for the drugs and infusion. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says payment for these services is bundled into the 
member's ambulance benefit payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that for ambulance services, payment for items and services is included in the fee schedule 
payment. 
 
We find that CPT codes J2405, J3490 and 96360 are not supported in the record. Specifically, payment for 
these services is included in the fee schedule payment for the transportation and mileage. Based on this 
information, we decided that Medicare rules for coverage of the drugs and infusion have not been met. 
Therefore, we decided that the Plan does not have to pay for ondansetron hydrochloride injection (J2405), 
unclassified drugs (J3490) and infusion (96360) provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the urgent care visits you had on August 
17, 2020, and August 20, 2020. 
 
You asked the Plan to reduce the copayments for the urgent care visits. You say that you weren't able to get in 
to see your PCP on an urgent basis, so you went to the urgent care next to your PCP's office.  You say that in 
the past, you have only paid a $25 copayment at this urgent care center.  You say that your copayment should 
be reduced to $25. The Plan denied your request. The Plan says you were charged this copayment 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 $45 
copayment per visit for urgent care.  
 
You have been asked to pay a $45 copayment per visit for the urgent care visits. 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 reduce the copayments for the urgent care visits you had on August 17, 2020, and August 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that Gelsyn-3 is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
Gelsyn-3 is not medically necessary. Our physician reviewer found the record does not show a trial of the plan 
preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90791, 90837) provided 
May 4, 2020 to May 18, 2020. 
 
You asked the Plan to pay for the outpatient mental health services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says this provider is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC?s) are 
not eligible for enrollment in the Medicare program.  
 
We looked at the file and Medicare rules. The provider was a type of provider not eligible for Medicare 
payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental 
health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient 
mental health services (90791, 90837) provided May 4, 2020 to May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the exam you had on November 20, 2019. 
 
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 50% 
coinsurance for each Medicare-covered physical examination.  
 
Review of the file shows that you had a physical exam on November 20, 2019. You have been asked to pay a 
50% coinsurance for the exam. The services falls within the physical examination 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 coinsurance for the exam you had on November 20, 2019.