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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that without these services the member will not be able to 
reach their baseline mobility. 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that 
the enrollee requires at least 3 hours a day 5 days a week, or 15 hours over 7 consecutive days, of therapy 
services. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided from October 17, 2017, to April 
26, 2018. 
 
You asked the Plan to pay for diabetic supplies. You say that this glucose monitoring system was covered by 
Medicare directly and should be covered by the Plan. The Plan denied your request. The Plan says the denial of 
payment for these supplies is correct, because this claim for payment was not submitted within the timely filing 
limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for diabetic supplies was not filed until June 23, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for diabetic supplies provided from October 17, 2017, to April 26, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says research has not found this device to be helpful for the enrollee's condition. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interlaminar/interspinous process stabilization/distraction device 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 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 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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient is 
living at home and is having more trouble performing activities of daily living. He has peripheral edema which 
interferes with use of his lower leg prosthetic. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. The patient 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 
patient 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that continued inpatient skilled nursing 
facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for 
coverage of continued inpatient skilled nursing facility care. 
 
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 continued SNF care. Our reviewer says 
that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found 
that you do not require skilled nursing or skilled therapy services on a daily basis. Additionally, you do 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an amniotic fluid allograft injection (Q4206). 
 
You asked the Plan to pre-approve an amniotic fluid allograft injection. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 an amniotic fluid allograft injection. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the clinical value and effectiveness of Amniotic Fluid Allograft 
Injection - Fluid Flow in the setting of advanced degenerative joint disease have not been demonstrated in the 
peer-reviewed literature. Therefore, the procedure is deemed not medically reasonable or 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 an amniotic fluid allograft injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an amniotic fluid allograft injection (Q4206).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found the records do not show that the 
enrollee meets Medicare coverage criteria for the PET scan. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) provided on July 10, 
2020. 
 
You asked the Plan to pay for the additional periapical x-ray. You say that your plan covers 2 exams and 2 
cleanings per year. You say that you do not know the difference between a comprehensive exam versus a 
periodic exam. You say that you do not know what type of x-rays you received. You also say you moved to a 
new state and it is not your fault that the dentist would not do a cleaning without doing a new patient exam and 
x-rays too. The Plan denied your request. The Plan says the additional periapical x-ray is not 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the additional periapical x-ray is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
additional periapical x-ray (D0230) provided on July 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan (J7321). 
 
You asked the Plan to pre-approve Hyalgan. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the member did not meet the step therapy requirement. 
 
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 Hyalgan. Our reviewer says that the 
provided medical records do not document that the enrollee has satisfied the step therapy requirements. Our 
physician reviewer found the medical records do not document that the enrollee has had previous treatment, 
contraindication, or intolerance to Orthovisc and Monovisc. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan (J7321).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 23650) provided on April 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 23650 is not supported in the medical record. Specifically, the records do not show that 
the services were provided by the billing provider. 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 pay for the 
services (CPT 23650) provided on April 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatment (endovenous ablation with 
sclerotherapy) for the enrollee. 
 
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied 
your request. The Plan says the provider did not submit clear documentation of reflux in the vein to be treated. 
 
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 procedures. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of activity-limiting symptoms. There is no documentation of 
concerted efforts at conservative therapy. There is no obvious contraindication to compression stockings. The 
veins in questions are not particularly enlarged. 
 
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 procedures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve varicose vein treatment (endovenous ablation with sclerotherapy) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care to begin on November 30, 2020. 
 
You asked the Plan to pre-approve IRF 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 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
vertebral compression fractures and a nasal fracture after a fall. Medical problems are stable. There are no 
identified problems that need inpatient medical management. There are no complex nursing or rehabilitation 
needs. You do 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 you 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 IRF care to begin on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for access to public golf clubs purchased on March 6 and March 
17, 2020. 
 
You asked the Plan to pay for access to public golf clubs. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
The rules say that Medicare does not cover fitness benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan reimburses up to $40 
per month for general access to public sports facilities upon submission to the Plan by the enrollee of an 
itemized receipt or other proof of payment and proof of participation. 
 
The Plan?s rules for coverage of fitness benefits have not been met because the receipts you submitted are not 
adequate proof of payment. Specifically, the receipts do not display the total amount you paid for access to 
public golf clubs on the dates of service in question. Therefore, we decided that the Plan does not have to pay 
for access to public golf clubs purchased on March 6 and March 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services (CPT 11921) provided to the enrollee 
on February 12, 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 the records do not 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. 
 
In this case, the CPT Code Manual definition of code 11921 is "Tattooing, intradermal introduction of 
insoluble opaque pigments to correct color defects of skin, including micropigmentation." 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation submitted was reviewed, and it does not meet the criteria. The procedure report does not include 
documentation that procedure was performed in connection with a covered post-mastectomy reconstruction. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for dermatology services (CPT 11921) provided to the enrollee on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's 
(PCP) specialty network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient physician services provided on June 17, 2020 billed with 
code 99232. 
 
You asked the Plan to pay for the inpatient physician services. You say that this should not be considered 
global to any other service. The Plan denied your request. The Plan says that these services were billed on the 
same date as other inpatient physician services which were paid to another provider of the same specialty in the 
same physician group. This means that both visits must be included and paid under a single code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that two inpatient physician visits can be paid for the same date of service when 
each physician is responsible for a different aspect of patient care.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There is not sufficient documentation provided by the plan to support that the 
physician services at issue are not separately payable. Although the National Provider Identification Numbers 
(NPI) of the two providers both indicate a specialty of Internal Medicine, the remaining evidence supports that 
they were responsible for different aspects of the patient's care.  
 
The denied claim was reported with a taxonomy code for Physical Medicine and Rehabilitation (PMR). The 
progress note for this visit clearly documents that this was a PMR evaluation and the reported diagnosis codes 
were for stroke and back pain. The other provider's claim had reported diagnoses of endocarditis and pleural 
effusion, which would not be related to either the enrollee's stroke or back pain. The Plan did not obtain a 
progress note for the other physician's services, but all evidence suggests it was unrelated to the PMR 
evaluation at issue in this case. Though the providers do have the same specialty based on the NPI number, the 
rules do allow for "circumstances where concurrent care may be billed by physicians of the same specialty". As 
such, we find that the denial of payment for these services has not been substantiated. Therefore, we decided 
that the Plan has to pay for the inpatient physician services provided on June 17, 2020 billed with code 99232.  
 
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.