Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from 
July 8, 2019 through November 25, 2019. 
 
You asked the Plan to pay for inpatient mental health care. You say that the stay was 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 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 inpatient mental health care. Our physician 
reviewer found based upon review the records provided it was not expected this enrollee would improve in a 
reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or 
others, no auditory or visual hallucinations and no abnormal behaviors. This patient was described as being 
calm and cooperative. 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 he did not have 
any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health plan's denial of 
continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental 
health treatment beyond the dates in question as noted above as the patient was not a danger to themselves or 
others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the patient?s condition or for the purpose 
of diagnosis. Our physician reviewer was unable to find an individualized treatment plan however the entire 
record is not present. It appears that the services were supervised and evaluated by a physician. Based upon 
review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of September 21, 2020 forward and could have been treated in a 
lesser restrictive setting as the patient was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations and was not showing any behaviors being cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient mental health care provided to the enrollee from July 8, 2019 through 
November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), specimen handling (99000), pap 
smear screening (Q0091), sign language/oral interpreter service (T1013), cervical cancer screening; pelvic and 
breast examination (G0101), and annual wellness visit (G0439) rendered by the out of network (OON) provider 
on February 19, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the office visit (99213), specimen handling (99000), pap smear screening (Q0091), 
sign language/oral interpreter service (T1013), cervical cancer screening; pelvic and breast examination 
(G0101), and annual wellness visit (G0439) rendered by the out of network (OON) provider on February 19, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a 
participating provider on April 25, 2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not think you should 
have to pay for this Covid-19 test. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for urgently needed services.  
 
You have been asked to pay a $20 copayment for an urgent care visit. Since an urgent care visit was provided, 
the correct copayment has been applied. An urgent care visit falls within the urgently needed services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an urgent care visit provided by a participating 
provider on April 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee from November 
11, 2019 through November 16, 2019. 
 
You asked the Plan to pay for the medical services. You say that this claim should fall under the 72 hour rule. 
The Plan denied your request. The Plan says the re-admission denial is upheld for lack of clinical 
documentation. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. The hospital did not 
provide sufficient information to allow a reasonable conclusion that the second admission was not preventable. 
There is no documentation on the preceding admission starting on November 8, 2019, available for review. 
Therefore, completeness of care, stability at discharge, and adequacy of discharge planning cannot be 
determined. After multiple attempts to obtain the first admission chart and information from the provider, none 
was sent to date. The re-admission denial is upheld for lack of clinical documentation. Therefore, we decided 
that the Plan does not have to pay for the medical services provided to the enrollee from November 11, 2019 
through November 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 13, 2020 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services received by a non-contracted provider in the plan service area were not 
for an urgent or emergent reason and were available to be provided in-network and were not authorized as 
required. 
 
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 medical services provided on January 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the mobile home visits. You say that it is the assisted living facility's 
responsibility to get authorization for services. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. 
 
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 medical services provided on January 10, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 19, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 medical services provided 
on May 19, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 pay for the Guardant360 panel rendered on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for waterproof tape (A4452), collagen dressing (A6021) and 
specialty absorptive dressing, wound cover (A6251) provided on March 12, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services should be included in the Part A SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the DME was used in a SNF or hospital. Therefore, we decided that the Plan does not have 
to pay for waterproof tape (A4452), collagen dressing (A6021) and specialty absorptive dressing, wound cover 
(A6251) provided on March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), unspecified preventive 
procedure (D1999) and therapeutic parenteral drug (D9610) provided on May 1, 2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140), unspecified preventive procedure (D1999) 
and therapeutic parenteral drug (D9610). You say that the doctor extracted a tooth to correct the issue. You say 
that you are appealing the denial due to the complications and expenses you incurred. The Plan denied your 
request. The Plan says the oral evaluation is only covered once per plan year and the procedure and therapeutic 
parenteral drug are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one limited oral evaluation per plan year. The Plan paid for an oral evaluation provided on March 2, 2020, 
which exhausted your benefit. The unspecified preventive procedure and therapeutic parenteral drug are not on 
this list and are not covered supplemental benefits. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation (D0140), unspecified preventive procedure (D1999) and therapeutic parenteral drug 
(D9610) provided on May 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 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 the member can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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's medical status does not currently 
require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that the patient's 
functional status requires an intensive rehabilitation therapy program provided in an IRF. 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: Favorable

We decided that the Plan does have to pre-approve magnetic resonance imaging (MRI) services.You asked the Plan to pre-approve MRI services. You say that the records provided support the need for the requested MRI.The Plan denied your request. The Plan says the clinical information provided does not meet the criteria for coverage of an MRI.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI services. Our reviewer says that the requested MRI services are medically reasonable and indicated. Our physician reviewer found, in the absence of trauma, plain films are of low utility. MRI services are appropriate for unexplained knee pain in this instance. The enrollee's pain has not improved. An MRI will be able to diagnose the cause of knee pain and determine stability of the knee most efficiently.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI services have been met.Therefore, we decided that the Plan does have to pre-approve magnetic resonance imaging (MRI) services. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation supports the 
request for LTACH care. The Plan denied your request. The Plan says the enrollee does not require services in 
the LTACH that are not available in the acute care hospital where she is currently being safely cared for. 
 
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 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 he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
 
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.
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 the member would be best served with acute 
inpatient rehabilitation to increase his strength and independent functioning. The Plan denied your request. The 
Plan says that the member may be equally well served at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for frequent falls and 
knee pain. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports the need for physical and occupational 
therapy but does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 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: 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 IRF care is the best chance of success for the 
enrollee's current surgical recovery, comorbidity management, and rehabilitation. The Plan denied your 
request. The Plan says IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires or can fully tolerate an intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.