Persius/hicric huggingface dataset:
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of IRF 
care. The Plan says that the enrollee's needed care is not complex enough and can instead be received at a lower 
level. 
 
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 meningioencephalitis, seizures and acute kidney injury. The enrollee's medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy but it does not 
support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist physician service. 
 
You asked the Plan to waive the copayment for the specialist new patient visit while in outpatient hospital 
observation status. You say that you were visited while in the hospital. 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 $35 
copayment for specialist Physician/Practitioner services.  
 
You have been asked to pay a $35 copayment for the new patient visit while in outpatient hospital observation 
status. This service falls within the Physician/Practitioner specialist services benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the physician service.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the excision of the tendon sheath lesion 
(26160) provided on February 3, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 30% 
coinsurance for each in-network surgical or observation room service you get at an outpatient hospital.  
 
You have been asked to pay $492.62 ($1,642.05 Plan allowed amount x 30% coinsurance) for the in-network 
surgical service provided at an outpatient hospital. 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 excision of the tendon sheath lesion (26160) provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphine sulfate injection services coded J2274 and the 
clonidine hydrochloride injection services coded J0735 provided on March 20, 2020. 
 
You asked the Plan to pay for the morphine sulfate injection services and the clonidine hydrochloride injection 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services billed are not supported b the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes J2274 and J0735 are not supported in the medical record. Specifically, the submitted 
documentation indicate that morphine and clonidine were mixed/compounded. Therefore, there is a more 
appropriate code for the services provided. Based on this information, we decided that Medicare rules for 
coverage of the morphine sulfate injection services and the clonidine hydrochloride injection services have not 
been met. Therefore, we decided that the Plan does not have to pay for the morphine sulfate injection services 
coded J2274 and the clonidine hydrochloride injection services coded J0735 provided on March 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the abdomen (74018) provided April 22, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the claim is a duplicate. 
 
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 74018 is not supported in the medical record. Specifically, the records do not support 
this service being billed more than once on the same date. This claim is duplicative. Based on this information, 
we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the 
Plan does not have to pay for an x-ray of the abdomen (74018) provided April 22, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that without intense rehab, the enrollee will not be able to 
overcome her medical problems. The Plan denied your request. The Plan says that the enrollee can safely 
receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently 
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that the patient's 
functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 a lower level of care could result in the enrollee not 
regaining full function. The Plan denied your request. The Plan says the enrollee does not have complex rehab 
needs, or need to see a rehab physician 3 times a week. 
 
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 was admitted for surgical repair of a hip fracture and was treated for health care associated 
pneumonia. Her medical problems are stable. 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. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says no authorization has 
been 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 did not pre-approve the 
home visit. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for a home visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myomo brace (L8702). 
 
You asked the Plan to pre-approve a Myomo brace. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is experimental. 
 
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 Myomo brace. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard 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 a Myomo brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Myomo brace (L8702).
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 that these services are medically necessary. The Plan 
denied your request. The Plan says that your needs maybe met in a less intensive setting such as a skilled 
nursing facility. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Tempur-Pedic mattress for the enrollee. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says the actual brand name item is not supported by the 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 mattress. Our reviewer says that the 
requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence that a pressure-relieving mattress is necessary for skin/wound healing. There is no 
evidence on a physical examination that indicates extenuating factors that require the Tempur-Pedic mattress 
over an alternative mattress. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Tempur-Pedic mattress for the enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can be safely treated at a skilled nursing facility level of 
care. 
 
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. The 
patient is generally medically stable after a below knee amputation with no evidence of complex medical issues 
that require monitoring by an inpatient physical medicine and rehab physician three times per week or need for 
acute rehab nursing care. He still needs physical therapy (PT) to improve his mobility. While he may benefit 
from continuing PT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day 
with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 23, 24, 25, & 26 and 
retainer crowns (D6750) for tooth #'s 22 & 27. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that your dentist told you that you 
need a bridge because the one you currently have is old. You also say that the condition of your teeth is really 
bad, and there is a lot of dental work that needs to be done. The Plan denied your request. The Plan says these 
services are not medically necessary. 
 
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 the pontics 
and retainer crowns when the services are medically necessary and reasonable.  
 
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 pontics and retainer crowns. Our 
reviewer says that the fixed mandibular bridge does not meet coverage criteria. Our physician reviewer found 
there are 4 anterior teeth to be replaced and missing posterior teeth. Our reviewer found that coverage is 
considered to replace two mandibular teeth and no posterior teeth missing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 23, 24, 25, & 26 and retainer crowns 
(D6750) for tooth #'s 22 & 27.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need more work to be able to walk better. 
The Plan denied your request. The Plan says that you do not require skilled nursing or skilled rehabilitative 
services on a daily basis. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional PT visits. 
 
You asked the Plan to pre-approve the eight (8) additional PT visits. You say that the additional therapy is 
medically necessary because you have been making progress. The Plan denied your request. The Plan says you 
do not meet the medical necessity criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 eight (8) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the requested additional therapy is not generally 
accepted as specific and effective therapy for your condition. You have had extensive therapy for this condition 
and it does not appear that you require the ongoing unique skills of a professional therapist to safely and 
effectively provide treatment. Services do not need to be by or under a therapist to be safely and effectively 
performed. You have been educated in a home exercise program and the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your 
current condition or to prevent or slow further deterioration. 
 
 
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 eight (8) additional PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve eight (8) PT visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you need extra transportation for your 
radiation therapy appointments. The Plan denied your request. The Plan says the denial of authorization for 
additional routine transportation trips is correct, because routine transportation beyond 60 one-way trips per 
calendar year is not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that additional routine transportation beyond 60 one-way trips for this year would exceed the Plan?s covered 
routine transportation benefit. At the time the Plan made their decision, the Plan said that you had 31 trips 
remaining for this year Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.