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 it is felt that the enrollee's condition requires 
continued inpatient care and intensive therapies. The Plan denied your request. The Plan says the member is 
high-functioning and would not require three hours of daily therapy in an IRF setting. 
 
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 enrollee was admitted to the hospital on 10/27/2020 due to weakness. By 11/1, 
she was ambulating with a walker. The enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollees care needs can be met at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99204) provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that medically necessary services were provided in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 office outpatient visit (99204) provided by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from June 
17, 2020, through  
June 29, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says all inpatient services require prior authorization. 
 
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 
services 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 a behavioral health inpatient admission provided from June 17, 
2020, through June 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services 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 services could be conducted in a short stay/observation level of care. 
 
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 enrollee presented with abdominal pain. While further evaluation is reasonable,  
there is insufficient documentation to show that this evaluation needs to occur at the inpatient level or will last 
two midnights. Furthermore, there is no valid physician order (dated, timed, signed) for inpatient level 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for admission to acute inpatient rehabilitation. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do require physical therapy and occupational therapy services, but based on the medical records provided 
you do not require an intensive inpatient rehabilitation therapy program. Our physician reviewer also found that 
there is no documentation that you require 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite of one surface (D2391) and resin-
based composite of two surfaces (D2392) provided. 
 
You asked the Plan to pay for the resin-based composites. You say that these services should be covered 
because you have a pamphlet from the Plan which indicates that dental coverage includes fillings. The Plan 
denied your request. The Plan says these services are not covered benefits under your dental plan. The Plan 
also says that you were not enrolled. 
 
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 pay for the resin-
based composite of one surface (D2391) and resin-based composite of two surfaces (D2392) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT Code 63650 x2). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the records do not show the enrollee has 
a condition for which this treatment is 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 services. Our physician reviewer 
found the patient does not have an evidence based indication for a spinal cord stimulation (SCS) trial. The 
patient also does not have a clearance from a psychologist or psychiatrist. The requested procedure is not 
medically reasonable or indicated. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 
x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography scan (LDCT) scan for 
lung cancer screening (G0297). 
 
You asked the Plan to pre-approve a LDCT scan for lung cancer screening. 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. 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 a LDCT scan for lung cancer screening. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found review of your 
telemedicine visit shows you are 77 years of age (within the age group necessary) but the number of pack years 
and the duration of smoking is not explained. For these reasons, the CMS criteria to approve a LDCT scan has 
not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a LDCT scan for lung cancer screening have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a low dose computed tomography scan (LDCT) scan for 
lung cancer screening (G0297).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids (V5261). 
 
You asked the Plan to pre-approve the hearing aids. You say that the hearing aids are medically necessary. The 
Plan denied your request. The Plan says hearing aids are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids 
(V5261).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Topamax 200 mg tablet. 
 
You asked the Plan to pre-approve Topamax. You say that the enrollee needs treatment with this drug. The 
Plan denied your request. The Plan says rules for pre-approval of self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Topamax 200 mg tablet.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 24, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. 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. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), advanced care planning (99497), 
annual alcohol screen (G0442), annual depression screen (G0444), intensive behavioral therapy (G0446) and 
annual wellness visit (G0439)   provided by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit, advanced care planning, annual alcohol screen, annual depression 
screen, intensive behavioral therapy and annual wellness visit. You say that you were required to find a new 
primary care physician. The Plan denied your request. The Plan says prior authorization must be obtained for 
non-emergent services rendered by an out-of-network provider. 
 
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 office visit (99214), advanced care planning 
(99497), annual alcohol screen (G0442), annual depression screen (G0444), intensive behavioral therapy 
(G0446) and annual wellness visit (G0439)   provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist at the 
in-network benefit level. 
 
You asked the Plan to pre-approve the referral. You say that you are only ophthalmic plastic and reconstructive 
specialist in the network. The Plan denied your request. The Plan says this will be processed at the out-of-
network benefit. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this referral at the in-network benefit level. Therefore, we decided that the Plan does 
not have to pre-approve a referral to an out-of-network ophthalmologist at the in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (K0553).You asked the Plan to pre-approvethe continuous glucose monitor. You say that the Continuous Glucose Monitor is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that in order for a Continuous Glucose Monitor to be covered, the enrollee must be insulin-treated with multiple (three or more) daily injections of insulin. We looked at the file and Medicare rules. The record shows that the enrollee does not use insulin injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that your records show that you have not completed your full course of treatment in the hospital.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 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 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 his ongoing confusion. 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-approveacute 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 services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says enough units have been approved to continue therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. 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 the requested additional therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and 
it does not appear that the enrollee's functional level requires the ongoing 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. The enrollee is competent in a home 
independent exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional physical therapy services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet joint injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the medical records do not document sufficient relief from previous 
injections. 
 
The Plan must follow Medicare rules. Medicare rules say that injections may be repeated if the first injection 
results in significant pain relief (at least 50%) for at least 3 months. 
 
We looked at the file and Medicare rules. The records do not show that previous injections provided at least 
50% pain relief for 3 months or more. Based on this information, we decided that Medicare rules for coverage 
of facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve 
facet joint injection (64493, 64494, 64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine vision services provided on July 10, 2020. 
 
You asked the Plan to pay for the routine vision services. You say that you would like reconsideration because 
the Plan should pay $220 for these services. The Plan denied your request. The Plan says you have an 
allowance of $100 for vision hardware. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan offers a $100 allowance for vision hardware. 
 
 
 
 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the routine vision services have not been met. Specifically, the record indicates that the Plan 
reimbursed you $100 for the vision hardware. This is the correct amount per your Plan contract. Therefore, we 
decided that the Plan does not have to pay for routine vision services provided on July 10, 2020.