Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care beginning September 28, 
2020. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was 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 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 mental health care. Our 
physician reviewer found, based upon review of the records provided, it was not expected you would improve 
in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted, 
and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any 
acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided 
at the acute inpatient level of care rather than a lower level of care beyond the dates in question, as you did not 
have dangerousness to self or others but were compliant with your treatment. The health plan's denial of 
continued inpatient psychiatric services is appropriate. You did not appear to require inpatient mental health 
treatment beyond the date in question as you were not a danger to yourself or others and did not have any 
auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services were reasonably expected to 
improve your condition or for the purpose of diagnosis beyond the date in question. Our physician reviewer 
was unable to find an individualized treatment plan; however, the entire chart is not present. It did appear that 
the records were supervised and evaluated by a physician. Based upon review, the records provided for the 
admission do not meet the criteria for continued acute inpatient mental health treatment for the dates in 
question of September 28, 2020, forward, as you were not shown to be a danger to yourself or others. You were 
not showing any auditory or visual hallucinations and were cooperative/compliant with treatment while not 
showing any threats to safety. 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care beginning September 28, 2020.
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 the LTACH services. 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 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 the patient appears to be improving but still requires additional short term (less than 
25 days) of additional acute care services for weaning. There patient does not require services at the LTACH 
that are not already available at the current hospital. There are no services at the LTACH that the patient 
requires that are not already available and covered at the current hospital. Ongoing care at the current location 
appears to be most appropriate for the short term. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer to a lower level of care may be considered soon, 
based on the improvement in the clinical course. 
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forskilled nursing facility (SNF) services provided from April 4, 2020, through May 12, 2020.You asked the Plan to waive the copayment forthe SNF services. You say that the enrollee had to stay quarantined for the first 14 days of this stay, and then had to stay longer due to medications he was given.The Plan denied your request. The Plan says this copayment 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). The enrollee's contract with thePlan clearly says that enrollees must pay a $0 copayment for days 0-20, a $135 copayment per day for days 21-45, and a $0 copayment for days 46-100 for skilled nursing facility services. Records show that the enrollee was in the SNF for a total of 38 days. The Plan charged him $0 per day for the first 20 days in accordance with the Plan contract. The Plan then charged a $135 copayment per day for the next 18 days, for a total of $2430. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan,and it applies regardless of the reason for the stay.Therefore, we decided that the Plan does not have to waive the copayment forskilled nursing facility (SNF) services provided from April 4, 2020, through May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the heart for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has risk 
factors for CAD but is already being managed with both anti-hypertensive therapy and statins for her lipids. 
She has also had a nuclear stress as part of her dyspnea evaluation which did not show evidence of ischemic 
heart disease. She is scheduled to have an echocardiogram as well to further assess her dyspnea symptoms. 
Published guidelines recommend using coronary calcium scanning to risk stratify asymptomatic patients 
patients at intermediate risk of cardiovascular disease in order to make a determination about using lipid 
lowering and other risk lowering therapies. This non-contrast calcium scan would not provide information on 
the extent of any coronary artery blockages. The test is therefore not medically necessary or appropriate to use 
in evaluating dyspnea symptoms. In addition, the enrollee is already being treated with risk factors 
modification of lipid lowering (statin) and anti-hypertensive therapy and AHA/ACC guidelines recommend 
treating to LDL cholesterol and BP goals to guide this therapy. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the heart for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran orthosis (L2385) provided April 10, 2020.You asked the Plan to pay forthe orthosis. You say that this item was medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or proof of delivery. The proof of delivery shows the items were delivered on March 27, 2020, butthe claim is dated April 10, 2020. The claim date of service must be the date the items were delivered. The record shows that the Plan made several attempts to obtain the necessary documentationwithout success.Therefore, we decided that the Plan does not have to pay foran orthosis (L2385) provided April 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from September 28, 2020, 
through discharge. 
 
You asked the Plan to pre-approve continuation of 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 continuation of SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require 
skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or 
intensity of service criteria for 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF care from September 28, 2020, through discharge.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
September 21, 2020, through current. 
 
You asked the Plan to pre-approve continuation of inpatient mental health 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 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 continuation of inpatient mental health 
care. Our physician reviewer found based upon review the records provided it was not expected this enrollee 
would improve in a reasonable period of time beyond the dates in question as they were not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care beyond the dates in question as they did not have any suicidal or homicidal 
thoughts, auditory or visual hallucinations or abnormal behaviors. The health plans denial of continued 
inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health 
treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not 
have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place 
beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve the patients condition or for the purpose of diagnosis. Our 
physician reviewer was unable to find an individualized treatment plan however the entire record is not present. 
It appears that the services were supervised and evaluated by a physician.  
Based upon review the records provided, this patient does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of September 18, 2020 forward and could have 
been treated in a lesser restrictive setting as they were not showing any suicidal or homicidal ideation, auditory 
or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and 
compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation of inpatient mental health care from September 
21, 2020, through current.
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 there are identifiable skilled nursing service 
needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or 
therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service 
criteria for 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit rendered on June 24, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 
months. 
 
We looked at the file and Medicare rules. The file shows that you received an annual wellness exam on July 2, 
2018 for which the Plan approved and paid. The annual wellness visit on June 24, 2019 was performed less 
than 12 months from your previously covered exam. 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 
the annual wellness visit rendered on June 24, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral breast magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve the breast MRI. You say that you believe that this imaging is necessary to 
check for cancer. The Plan denied your request. The Plan says that the Medicare criteria for MRI of the breasts 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that breast MRI is covered when needed due to 
inconclusive diagnosis after standard workup.  
 
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 breast MRI. Our reviewer says that 
the requested imaging is considered reasonable and necessary in this case. Our physician reviewer found the 
enrollee is a female with a family history of breast cancer with recent bloody discharge from the breast. 
Mammography could not find corresponding lesion to explain blood discharge. Standard workup has been 
inconclusive. Given family history and no corresponding findings on mammography for bloody discharge, the 
enrollee is high risk and this imaging is 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 breast MRI have been met. Therefore, we decided that the Plan has to pre-
approve bilateral breast magnetic resonance imaging (MRI).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services received on May 
24, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim was processed appropriately. 
 
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 $90 
copayment for emergency department services.  
 
You have been asked to pay a $90 copayment for the services. The services fall within the emergency 
department 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 emergency room 
services received on May 24, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve non-emergency ambulance services. 
 
You asked the Plan to pre-approve non-emergency ambulance services. You say that the member is morbidly 
obese and has atrophy of muscles, in both upper and lower extremities. In addition, the member has a lack of 
coordination, diminished motor and sensory function and cannot sit safely unattended in a moving wheelchair 
van. You state the member is being transported by ambulance for dialysis treatments. The Plan denied your 
request. The Plan says that there was no documentation that the member is unable to get up from bed without 
assistance, unable to ambulate and unable to sit in a chair or a wheelchair. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. 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 pre-approve non-emergency ambulance services. 
Our physician reviewer found the patient is morbidly obese and has atrophy/weakness and is not able to be 
transported safely via wheelchair van due to these challenges. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance services have been met. Therefore, we decided that 
the Plan has to pre-approve non-emergency ambulance services.  
 
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 pre-approve radiation therapy for non-small cell lung cancer. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the reason this request cannot be approved is because the type of treatment requested is 
not supported to treat the patient's cancer type based on the way it currently appears. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Stereotactic Body Radiation Therapy (SBRT) was to be done to the largest lesion. This will be 
to no avail for a patient with multiple metastasis. A systemic approach is needed. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiation therapy for non-small cell lung cancer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 13, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says non-urgent services should be from network providers who are contracted with 
the member's health plan and listed in the Provider Directory. 
 
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 laboratory services provided to the enrollee on 
February 13, 2020.