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 you need therapy and monitoring. The Plan denied 
your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you had a 
right hip replacement on October 7, 2020. The note on October 14, 2020 states your pain was well-controlled 
and you were not weight bearing on your right leg. 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 do not need intensive physician and nursing oversight only in an IRF. You may benefit from further 
therapy but do not require an intensive therapy program 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for 
SNF care. The Plan denied your request. The Plan says the enrollee has neither functional nor medical needs 
that warrant a SNF admission. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and 
inhaled medications, had stable vital signs, and was referred to Hospice care. The enrollee received physical 
therapy and occupational therapy. The enrollee was at a contact guard to moderate assist level with functional 
mobility and activities of daily living. There are no identifiable skilled nursing service needs. There are no 
identifiable skilled therapy service needs. The enrollee does not meet the 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ketamine infusions provided from March 6, 2020 to April 8, 
2020. 
 
You asked the Plan to pay for Ketamine. You say that all of your medical professionals agree that this 
treatment is medically necessary, and these services were not available from any in-network provider. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because Ketamine is 
only considered medically necessary for certain specific indications which you did not meet. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiary must furnish to the Plan sufficient 
information to determine whether payment is due and the amount of payment for a claim. The information 
submitted must corroborate the medical records and confirm that Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. You did not submit any medical records of the services for which you 
are requesting payment. The documentation includes prior notice from the provider that these services may not 
be covered by the Plan. Although Ketamine is not explicitly excluded from Medicare coverage, Medicare 
requires that sufficient medical documentation be submitted to confirm that coverage criteria have been met, in 
this case that the drugs provided were medically reasonable and necessary. Therefore, you have not furnished 
sufficient information to the Plan to justify the requested reimbursement. Based on this information, we 
decided that Medicare rules for coverage of Ketamine have not been met. Therefore, we decided that the Plan 
does not have to pay for Ketamine infusions provided from March 6, 2020 to April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive hearing test (92557) 
provided on March 4, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment 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 $40 
copayment for an exam to diagnose and treat hearing and balance issues.  
 
You have been asked to pay a $40 copayment for hearing exam provided. 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 comprehensive hearing test (92557) provided on March 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF. You say that the enrollee is unable to balance or walk without 
assistance, and lives alone at home. You say that SNF care is medically necessary. The Plan denied your 
request. The Plan says the enrollee's clinical condition does not require daily skilled services as an inpatient in a 
skilled nursing facility. 
 
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 the SNF. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had 
stable vital signs. The enrollee had acute on chronic kidney disease and dialysis was deferred for now. The 
enrollee was treated for congestive heart failure and suspected shingles. The enrollee received physical therapy 
and occupational therapy in the acute hospital. The enrollee was at a supervision to contact guard assist level 
 
 
with functional mobility, including gait to 120 feet with a rolling walker. The enrollee required varying assist 
with activities of daily living. There are no identifiable skilled nursing service needs. While there are 
identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the 
severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 the SNF have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and abutment 
supported crown (D6068). 
 
You asked the Plan to pre-approve the custom fabricated abutment (D6057) and abutment supported crown 
(D6068). You say that it is a lot to pay out of pocket and this needs to be done. You say that some of this 
should be covered under the dental plan. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 
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 the 
custom fabricated abutment (D6057) and abutment supported crown (D6068).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot take care of himself. The 
Plan denied your request. The Plan says that the enrollee does not require any daily skilled nursing services and 
does not require daily skilled therapy. 
 
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 the enrollee's condition does not 
meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 drug testing services provided on March 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) received 
on March 6, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not have money 
with which to pay the assessed copayment. The Plan denied your request. The Plan says you were charged this 
cost sharing 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $250 for these services. 
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 ambulance services (A0427) received on March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Vertiflex Superion spacer 
is considered experimental/investigational in nature, as more research is needed to show its safety and efficacy. 
The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower 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. You 
are medically stable with spinal stenosis and lumbar radiculopathy with decreed function. There is no evidence 
of need for supervision by physical medicine and rehab physician three times a week or needing acute rehab 
nursing care. The documentation does not support that there is a need for an intensive therapy program with 3 
hours a day and an interdisciplinary approach to rehab care. Your rehab needs can be met in an alternate, less 
intense setting. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a 
participating provider on May 23, 2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to get a Covid-19 
test. You say that you never received one. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
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 $60 
copayment for urgently needed services.  
 
You have been asked to pay a $60 copayment for an urgent care visit. The correct copayment has been applied 
to the urgent care visit that was provided. An urgent care visit falls within the urgently needed 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 an urgent care visit provided by a participating 
provider on May 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided to the enrollee from April 1, 
2020, to April 9, 2020. 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says the services 
were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient services must be billed with the 
correct number of days of care.  
 
 
 
We looked at the file and Medicare rules. The provider in this case billed 9 days of care. However, the records 
show that only 8 days of care were provided. The date of discharge/death should not be included in the number 
of days of care. Medicare does not pay for the date of discharge or death. Based on this information, we 
decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for the outpatient services provided to the enrollee from April 1, 2020, to 
April 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee requires a SNF level of care and 
should not be discharged home. The Plan denied your request. The Plan says the enrollee's clinical condition 
does not require daily skilled services as an inpatient in a skilled nursing facility. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and clear lungs. The enrollee received physical therapy, speech therapy, and 
occupational therapy in the acute hospital. The enrollee was at a moderate to maximal assist level for functional 
mobility. The enrollee required varying assist with activities of daily living. The enrollee tolerated a pureed diet 
and thickened liquids. There are no identifiable skilled nursing service needs. While there are identifiable 
 
 
skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on January 6, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says all non-emergent services 
received with a non-Plan provider require approval by the Plan prior to the services being rendered. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for DME provided on  
January 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health/hospice aide services in home health or hospice 
settings, each 15 minutes  (G0156) and  direct skilled nursing services of a registered nurse in the home health 
or hospice setting, each 15 minutes (G0299) provided May 1, 2019 to May 31, 2019. 
 
You asked the Plan to pay for the home health services. You say that the enrollee has both in-network and out-
of-network benefits and the account should be paid in full. The Plan denied your request. The Plan says RAP 
required in order to process final per Medicare guidelines required RAP claim and Q codes to process. 
 
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, Per Medicare guidelines, RAP claim was not billed, and the billed claim was not a ?No-RAP" 
LUPA and missing Q-codes. A RAP and a claim must be submitted for all episodes/periods of care for which 
Medicare makes payment based on HIPPS codes. However, if the HHA is aware prior to billing Medicare that 
it will supply fewer visits than the LUPA threshold in the episode/period, it may submit only a claim. In these 
 
 
cases, the claim is called a ?No-RAP LUPA", since the HHA is aware the claim will be paid a LUPA payment 
adjustment based on national standard visit rates. The location where services were provided must always be 
reported along with the first visit reported on the claim. In addition to reporting a visit line using the G codes as 
described above, HHAs must report an additional line item with the same revenue code and date of service, 
reporting one of the three Q codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge (e.g., a 
penny). If the location where services were provided changes during the episode, the new location should be 
reported with an additional line corresponding to the first visit provided in the new location. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health/hospice aide services in home health 
or hospice settings, each 15 minutes  (G0156) and  direct skilled nursing services of a registered nurse in the 
home health or hospice setting, each 15 minutes (G0299) provided May 1, 2019 to May 31, 2019.