Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee no longer needs care at the SNF level. 
 
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 records show that the enrollee no longer 
has identifiable skilled nursing or rehabilitation needs. The enrollee 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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from January 8, 2021, 
forward. 
 
You asked the Plan to pre-approve 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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided, you do not meet the criteria for treatment in 
an acute inpatient mental health treatment beyond the date in question of January 8, 2021, forward and could 
have been treated in a lesser restrictive setting as you 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 inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care from January 8, 2021, forward.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care received January 24, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the copayment can only be waived if you are admitted to the 
hospital within 24 hours. You were not admitted to the hospital on January 24, 2020. 
 
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 
copayment for emergency care.  
 
You have been asked to pay a $50 copayment for emergency room services. Emergency room services falls 
within the emergency care 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 January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9940). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need the night guard due to grinding 
your teeth while you sleep. You also say that you are only supposed to have a copay of $105.00 per the 
documentation from the Plan. The Plan denied your request. The Plan says this procedure code is not in the 
current approved Current Dental Terminology (CDT) code set, and the Plan is unable to pay for this service. 
 
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. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard (D9940).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new prosthetic leg with new foot. 
 
You asked the Plan to pre-approve new prosthetic leg with new foot. You say that the service is medically 
necessary. The Plan denied your request. The Plan says although a new socket appears necessary, a new 
prosthetic foot is not necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the replacement of a prosthesis is covered when 
certain requirements are met. 
 
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 new prosthetic leg with new foot. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no evidence in 
the treating physician note that indicates that you require a new prosthetic foot or that there is a change in your 
physiological condition. In addition, there is no evidence that there is irreparable wear of the device or a part of 
the device or that the condition of the device, or part of the device, requires repairs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of new prosthetic leg with new foot have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a new prosthetic leg with new foot.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a Level 5 office visit with a pain 
management 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 documentation provided by the physician does not support the need for an Office 
Visit Level 5. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the request is for a level 5 office visit. This would be an extensive review of systems and longer duration 
visit with complex decision making. You do not have an extensive or complex medical history. An office visit 
of a lower intensity is appropriate, medically reasonable and 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for a Level 5 office visit with a pain management provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (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 a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature. 
 
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 spacer 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, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
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 based on the medical records provided there is no documentation that the patient requires skilled nursing 
services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse is not required to 
safely and effectively provide medically necessary and reasonable treatment. This patient does require skilled 
therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist is required to safely 
and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. 
This patient does not require the services on an inpatient basis, in a SNF setting.  Services in the home with 
home health or in a long-term care facility on a part time basis appear appropriate in this case. 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve sixteen (16) fractions (treatment sessions) of Rotational Arc 
Therapy. 
 
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 doctor has requested a greater number of daily treatment doses than is needed 
and only twenty-eight (28) daily treatment doses are allowed for the member's treatment course. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the issue is the appropriateness of 44 fractions vs. moderate hypofractionation. Treatment with 
more fractions is costlier, which is the root of the dispute. However, 44 fractions in considered acceptable 
(albeit not preferable) by NCCN guidelines and ASTRO, ASCO, and AUA Evidence-Based Guideline with 
the expert guidelines acknowledging some limitations in the data. GI toxicity was discussed as a rationale for 
conventional fractionation in this patient. As such, our physician reviewer found that standard medical 
necessity criteria are met as the treatment with 44 fractions of IMRT would be "furnished in accordance with 
accepted standards of medical practice". 
 
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 sixteen (16) fractions (treatment sessions) of Rotational Arc Therapy.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 enrollee has not required prolonged mechanical ventilation. The enrollee still 
requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. 
The enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee 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. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ECG services (CPT 93010) provided to the enrollee on June 
12, 2020. 
 
You asked the Plan to pay for the ECG. You say that this should be paid for. The Plan denied your request. The 
Plan says payment for this service would be included in the part-A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93010 is "Electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only." 
 
We asked our coding 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 ECG. Our reviewer says that the services 
at issue in this case were not supported by the medical records. Our coding reviewer found per Medicare 
guidelines; Code of Federal Regulations (CFR) 42 CFR 409.3 and Code of Federal Regulations (CFR) 42 CFR 
412.50.  The facility or hospital must furnish services to the beneficiary either directly or under arrangements 
made between the hospital and facility and outside vendor. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ECG have not been met. Therefore, we decided that the Plan does not have 
to pay for ECG services (CPT 93010) provided to the enrollee on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provisional crown provided on July 1, 2020. 
 
You asked the Plan to pay for the provisional crown. You say that you were initially charged $450 up front for 
dental services. You also say that a refund was refused, and you found out a claim was never sent to your plan. 
The Plan denied your request. The Plan says this service 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. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
provisional crown provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) 
provided on February 3, 2020. 
 
You asked the Plan to pay the in network rate for the limited oral evaluation. You say that you were given this 
provider's information by a plan representative. You say that you were advised they would be in network. You 
also say that you spent a lot of time on the phone and no one was helpful. The Plan denied your request. The 
Plan says the limited oral evaluation is not listed as a covered service. 
 
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. Therefore, we decided that the Plan does not have to pay the in 
network rate for the limited oral evaluation (D0140) provided on February 3, 2020.  
 
Your complaint about spending so much time on the phone with no help is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network facility. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 facility.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility staff to 
verify eligibility and to obtain proper authorization. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because this provider is out-of-network with the Plan and authorization was 
not obtained. 
 
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 medical services provided on July 15, 2020 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram rendered on 
August 31, 2020. 
 
You asked the Plan to waive the deductible for these services. You say that you have not been charged for this 
service in the past. The Plan denied your request. The Plan says the deductible was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the advanced imaging service 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible for your covered medical services. This cost sharing is a contractual obligation that had not been 
met at the time these services were received on August 31, 2020. Therefore, we decided that the Plan does not 
have to waive the deductible for the diagnostic mammogram rendered on August 31, 2020.