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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but you do not require an 
intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you have used the six (6) approved PT 
visits and you are in need of more visits as you are learning to walk again. You say that you are in a lot of pain 
and you need to be able to bend your foot. The Plan denied your request. The Plan says additional PT visits are 
not medically necessary. 
 
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 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 prior therapy for this condition and received 
orthotics. A document dated September 28, 2020 indicates that you were dispensed a custom ankle/foot 
orthosis. You are ambulating and relating significant improvement in pain, function, gait and would like more 
therapy now that you have a brace. You are no longer taking narcotics. The documentation does not support 
that you require the unique skills of a professional therapist to safely and effectively provide treatment, or that 
the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist.  
 
 
 
You have had prior therapy but the therapy notes are not submitted. Your functional level on the September 28, 
2020 document does not indicate that the specialized skill, knowledge and judgment of a qualified therapist 
is  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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy PT visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan the abdomen and pelvis for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no reason for another test. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found a review of the records 
shows the ultrasound report of 7/13/20 describing a non-obstructive 3 mm stone in the interpolar region of the 
right kidney.  There are no plans discussed concerning lithotripsy or other therapeutic plan due to this small 
stone without hydronephrosis. According to the notes the patient desires to know whether a definite stone is 
present thus the order for CT. The review of the ultrasound report does not indicate equivocation concerning 
the small stone by the radiologist. There are no symptoms such as flank pain or hematuria to justify a CT as 
medically necessary at this point. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan the abdomen and pelvis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and extraction 
provided on April 27, 2020. 
 
You asked the Plan to pay for the limited oral evaluation, intraoral x-ray and extraction. You say that according 
to your plan you are to pay 45% for an extraction and 50% for an exam and x-ray. The Plan denied your 
request. The Plan says payment cannot be issued for services performed by a provider who has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation, intraoral x-ray and extraction provided on April 27, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Enhertu (J9358). 
 
You asked the Plan to pre-approve Enhertu. You say that transitioning to this drug would benefit the enrollee. 
The Plan denied your request. The Plan says that this drug is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enhertu. Our reviewer says that the 
criteria for coverage of Enhertu are met in this case. Our physician reviewer found while the requested use of 
Enhertu is not FDA-approved for the enrollee's diagnosis, the use is supported by clinical research that appears 
in a CMS-approved medical journal. The documentation support that the requested drug is safe and effective 
and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have been met. Therefore, we decided that the Plan has to pre-approve 
Enhertu (J9358).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (C9752, 22899). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says this procedure is considered experimental and is not covered. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (C9752, 22899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you need these supplies because of a medical issue.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology examination of tissue (88305) provided on 
June 11, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the pathology examination of tissue. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the pathology examination of tissue (88305) 
provided on June 11, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that new dentures are medically necessary so the enrollee can eat properly. You also say that the enrollee 
cannot afford to pay out of pocket for them. The Plan denied your request. The Plan says these services are not 
covered benefits under the enrollee's plan. 
 
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 a 
complete maxillary denture and a complete mandibular denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on June 4, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges 
because this was a pre-operative visit. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $50 
copayment for each specialist visit.  
 
You have been asked to pay a $50 copayment for specialist services. Specialist services fall within the 
physician/practitioner services, including doctor's office visits 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 specialist services provided on June 4, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that there is no medical complexity that would require frequent oversight by 
a rehabilitation physician. 
 
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 does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to her extreme weakness and immobility. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you 
had on, at a freestanding radiology facility. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were not told before the procedure 
that you would have a copayment. 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 $150 
copayment for advanced imaging services received in a freestanding radiological facility.  
 
You have been asked to pay a $150 copayment for the MRI. The MRI falls within the advanced imaging 
services received in a freestanding radiological 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 magnetic resonance imaging (MRI) you had, at a freestanding 
radiology facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection of incremental dosages of allergen (95117) 
provided on May 27, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the injection of incremental dosages of allergen. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the injection of incremental dosages of allergen 
(95117) provided on May 27, 2020, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee 
does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily 
basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient 
basis, only in a skilled nursing facility setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on August 3, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed based on the Current Procedural Terminology (CPT) code submitted. The Plan 
denied your request. The Plan says prior authorization was not obtained by the facility or the provider; 
therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the established patient office or other outpatient 
visit (99214) provided on August 3, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of cutaneous vascular proliferative lesions 
(17108. 
 
You asked the Plan to pre-approve destruction of cutaneous vascular proliferative lesions. You say that you 
would like reconsideration because this service is medically necessary as is stems the process of your 
condition. The Plan denied your request. The Plan says this service is considered cosmetic. 
 
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 destruction of cutaneous vascular 
proliferative lesions. Our reviewer says that the requested service is not medically reasonable and necessary. 
Our physician reviewer found laser treatment is not the standard of care for the member's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction of cutaneous vascular proliferative lesions have not been met. 
Therefore, we decided that the Plan does not have to pre-approve destruction of cutaneous vascular 
proliferative lesions (17108.