Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan and an ankle-brachial index for the 
enrollee. 
 
 
 
You asked the Plan to pre-approve the studies. You say that this is needed for continuity of care and monitoring 
of disease process. The Plan denied your request. The Plan says the records do not show signs of poor blood 
flow to the legs. 
 
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 studies. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found it is unclear if the study in question is a carotid duplex or lower extremity arterial duplex. With respect to 
the lower extremities, there is no documentation provided of lower extremity symptoms and there is 
documentation of normal pedal pulses. There is no patient assessment documented in the medical records 
provided that there was a concern about lower extremity artery perfusion or a plan for lower extremity arterial 
studies. 
 
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 studies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a duplex scan and an ankle-brachial index for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on August 14, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you should only be charged one 
copayment because the two CT scans could have been done on one day. The Plan denied your request. The 
Plan says you have been charged 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 $150 
copayment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRAs, 
MRIs, CT scans, PET scans, and hyperbaric oxygen therapy.  
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the ?Outpatient 
diagnostic tests and therapeutic services and supplies? 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 CT scan provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. Wherever such a combination exists, there is a use additional code note at the 
etiology code, and a code first note at the manifestation code. These instructional notes indicate the proper 
sequencing order of the codes, etiology followed by manifestation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Specifically, the record shows that the claim was billed 
with primary diagnosis code J91.0. This code has a code first note, which means it is a manifestation code and 
must be sequenced after an etiology code. Therefore, we decided that the Plan does not have to pay for the 
services provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with high gold content cap for bridge 
(tooth #10). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
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. The Plan covers 
crowns/bridges/inlay/onlay/periodontal work once per tooth every five years. 
 
This same service for the same tooth was last received. This is less than five years ago. 
Based on this information, we decided that the Plan's rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a white glass with high gold content cap for 
bridge (tooth #10).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the chest without contrast 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 that a chest x-ray is required first. 
 
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 medically reasonable and necessary. Our physician reviewer found a review of the records 
showed mention of a chest x-ray, but no report of this is in the chart. Since the enrollee has PFT that 
suggests possible restrictive lung disease, and he has shortness of breath it would be meaningless to repeat a 
chest x-ray since the diagnosis of restrictive lung disease usually is made on CT rather than plain films. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the chest without contrast for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Linzess.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 there are no services offered at the skilled 
nursing facility that are not offered at the inpatient rehab facility. Admission to a SNF for inpatient skilled 
rehab services was not 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the program is more intense and will work with the 
enrollee more. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, 
multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that the enrollee is at a contact guard assist level for sitting up, lying down, standing up, and walking using a 
rolling 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory work provided on September 
3, 2020. 
 
You asked the Plan to waive the deductible for the laboratory work. You say that the laboratory work was done 
as a part of your annual physical and should not be billed for these services. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible that applies towards diagnostic laboratory tests. 
 
The laboratory work you asked the Plan to waive the deductible for falls within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible that applies towards diagnostic laboratory work. Please 
note, laboratory work is not included in an annual physical. 
 
 
 
 
 
 
 
 
 
This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received 
on September 3, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the 
laboratory work provided on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology testing (81540) provided on August 4, 2020. 
 
You asked the Plan to pay for the oncology testing. You say that you would like reconsideration because this is 
a covered service. The Plan denied your request. The Plan says this is a non-covered service. 
 
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 pay for the oncology testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the member may be treated with FOLFOX which will cover both upper GI malignancy and 
pancreaticobiliary. 
 
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 oncology testing have not been met. Therefore, we decided that the Plan 
does not have to pay for oncology testing (81540) provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion implant 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 this is not accepted as a standard of medical practice. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Superion implant for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99233) provided on August 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the requested service is 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported unless the evaluation and management services are for unrelated problems.  
 
We looked at the file and Medicare rules. The services in question were provided on the same date of service as 
services rendered by a physician of the same specialty and in the same group practice. Per Medicare rules, the 
requested services are not payable, as only one E&M service is payable in this situation. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (CPT 99233) provided on August 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient psychiatric care provided from March 
7, 2020, through March 11, 2020. 
 
You asked the Plan to pay for the continued inpatient psychiatric care. You say that the enrollee required this 
entire stay to address her psychiatric issues. The Plan denied your request. The Plan says the enrollee could 
have been treated at a lower level of care beyond 3/6/2020. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 the continued inpatient psychiatric care. Our 
reviewer says that the enrollee does not meet the criteria for inpatient mental health care beyond the date in 
question. Our physician reviewer found the enrollee was treated medically starting on 2/24/2020 due to suicide 
attempt by overdose with anti-freeze and unknown pills. 
 
 She was then admitted to inpatient psychiatric care on 3/2/2020. Based upon review the records provided, it 
was expected this enrollee would not improve in a reasonable period of time for the dates in question as she 
had decreased suicidal no homicidal ideation noted and denied any auditory or visual hallucinations. The 
patient was compliant with treatment while not showing any acute threats to safety. It did not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care beyond the dates in question as she had decreased intensity of dangerousness to self with no 
dangerousness to others but was compliant with her treatment. The health plan?s denial of continued inpatient 
psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment 
beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual 
hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place 
beyond the date in question. 
 
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 continued inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pay for the continued inpatient psychiatric care provided from March 7, 
2020, through March 11, 2020.
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 SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found the medical record show at the time of admission, the enrollee required skilled rehab services to 
improve function due to weakness and deconditioning. Skilled nursing services included care for a feeding tube 
and IV antibiotics that were given every other day. There were no complications with the feeding tube. 
As of December 31, 2020, the enrollee did not require any skilled nursing or rehab services on a daily basis. He 
was not expected to make measurable gains within a reasonable and predictable period of time or require 
skilled therapy to prevent deterioration with mobility or daily activities. The enrollee does not require skilled 
therapy to establish a safe and effective maintenance program. The enrollee's function was at or near his prior 
level of function and he could be discharged to a lower level of care for further services.  
 
As of December 31, 2020, Medicare criteria for SNF admission are no longer 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 
2, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you were told there 
wouldn't be an extra charge. You say that you shouldn?t have to pay for two separate rides. The Plan denied 
your request. The Plan says the copayment applied 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 $350 
copayment for each Medicare-covered one-way trip via ground ambulance. 
 
You have been asked to pay a $350 copayment for the ambulance transport. The ambulance transport falls 
within the "Ambulance 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 
the ambulance transport provided on July 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 28, 2019, 
to February 26, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 28, 2019, to February 26, 
2019.