Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on December 
9, 2020. 
 
You asked the Plan to waive the copayment for the spinal injection. You say that you feel this should be 
covered because it was a simple injection and not an outpatient procedure. The Plan denied your request. The 
Plan says you have been asked to pay the correct cost-sharing amount. 
 
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 $350 
copayment per day for outpatient procedures and services, including, but not limited to, outpatient surgery 
performed in an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $350 copayment for the spinal injection. The spinal injection falls within the 
?Outpatient hospital services? benefit category. The medical record shows the cervical interlaminar epidural 
steroid injection was done under fluoroscopy which makes the procedure surgical in nature. 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 a spinal injection provided on December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the skin biopsy procedure you had on 
November 23, 2020, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the skin biopsy procedure. You say that you do not feel you are 
responsible for this copayment. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The Plan says that because the allowed amount for this procedure ($215.04) is less than your 
copayment obligation, you are responsible for the full allowed amount. 
 
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 $350 
copayment for outpatient surgery in a hospital outpatient facility.  
 
You have been asked to pay a $350 copayment for the skin biopsy procedure. The skin biopsy procedure falls 
within the outpatient surgery in a hospital outpatient facility 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 skin biopsy procedure you had on November 23, 2020, at an outpatient hospital 
facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the enterolysis services coded 44005 and the laparoscopy 
services coded 58661 provided on June 19, 2020. 
 
You asked the Plan to pay for the enterolysis services and the laparoscopy 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 
payable. 
 
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, we have confirmed that code 44005 
for the enterolysis services has a bundled relationship with code 58661 for the laparoscopy services and cannot 
be paid as billed. These codes cannot be paid as separate line items. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the enterolysis 
services coded 44005 and the laparoscopy services coded 58661 provided on June 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomics provided on October 1, 2020. 
 
You asked the Plan to pay for the targeted genomics. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. The provider should have verified the member's 
eligibility, health benefits and obtained authorization prior to the member s visit before providing services to 
the member as outlined on the member's ID card. 
 
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 
service at issue. 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 targeted genomics provided on October 1, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 
enrollee does not meet criteria for IRF admission. 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 pneumonia and a fall. 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, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99358) provided October 26, 2020 to 
October 28, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not billed with the appropriate code. 
 
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 99358 is Prolonged evaluation and management service 
before and/or after direct patient care. 
 
We find that CPT code 99358 is not supported in the medical record. Specifically, the services at issue were not 
after direct patient care. There is a more appropriate code to bill for the follow up service. Based on this 
information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99358) provided October 26, 
2020 to October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee 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 they are 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. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for an inpatient admission for a shoulder joint replacement surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that there is no documentation to support the expectation that the enrollee 
will require a greater than 2-midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the documentation supports that the right total shoulder arthroplasty has been approved. The 
procedure is typically indicated as an outpatient procedure, in the event of a lack of significant risk factors. 
There is adequate documentation regarding significant co-morbidities and/or past medical history that would 
increase the risk of peri- and/or post-operative complications (that would require presumptive approval of 
inpatient hospitalization.) These include aortic stenosis and aneurysm, along with diabetes. Therefore, the 
request for inpatient admission for a shoulder joint replacement surgery is 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for an inpatient admission for a shoulder joint replacement surgery.
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 additional trips to get to your 
appointments. The Plan denied your request. The Plan says the denial of authorization for additional routine 
transportation trips is correct. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. As of April 7, 2021, you have used 22 of 
the 24 one-way trips covered by this benefit. After the remaining 2 trips are used, this benefit will be 
exhausted. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation 
trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show a requirement for a breathing machine for a long 
period of time with failure of multiple weaning attempts. 
 
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 appears to be improving and only requires short-term additional acute 
care services to further stabilize that can be safely be received at the current facility. The patient does not 
require services at the LTACH that are not already available and covered at the current facility. There are no 
services at the LTACH that the patient requires that are not already available and covered at the current facility. 
Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer to a lower 
level of care may be considered soon when treatment has been completed. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of 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 in the Medicare rules section 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 
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, as a practical matter, you do 
not require the necessary services on an inpatient basis, only in a skilled nursing facility setting. Continued 
services in the acute inpatient rehabilitation facility until stable to return home with home health services or to 
transfer to a long-term care facility with part time services appears 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 inpatient skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission 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 in the Medicare rules section 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was readmitted to the 
hospital on March 29, 2021 due to inability to care for herself at home. She is wheelchair-dependent and 
requires assistance for all activities of daily living and transfers. She has no skilled nursing needs. She has 
skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee 
does not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission for the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request for the inpatient DRG does not meet the threshold for an 
intensity of services or underlying member hemodynamic instability that could only be managed in an acute 
inpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record does not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. The review indicates that the surgery CPT code 
given is no longer on the Medicare Inpatient Only List. The documentation preoperatively shows that the 
enrollee's hypertension, dyslipidemia and obstructive sleep apnea are stable on medication and the carotid stent 
and coronary stent are both historical. The enrollee's heart disease appears to be stable with controlled blood 
pressures and no complaints of chest pain during office visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient hospital admission for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no clinical advantage of LTACH over acute hospital. 
 
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. LTACHs are 
certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially 
different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute 
care services have not been denied. The documentation does not support that the enrollee in this case requires 
services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 
The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit 
from, and improve with, LTACH services. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 2, 2020, and November 11, 2020.
You asked the Plan to pay for the dental services. You say that you believe these services should be covered. The Plan denied your request. The Plan says your benefit maximum has been reached.
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 Plan offers a maximum plan benefit coverage amount of $1,000 per year, which applies to all supplemental (i.e., routine) dental services, both preventive and additional comprehensive, covered by the Plan. The contract clearly states that you are responsible for any cost above the $1,000 maximum. The record shows that you met the annual maximum benefit on November 11, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the dental services provided on November 2, 2020, and November 11, 2020.