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

 
We decided that the Plan does not have to pay for post stabilization care provided on December 30, 2019. 
 
You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration because 
the services rendered were medically necessary. The Plan denied your request. The Plan says the hospital failed 
to seek pre-approval for admission from the Plan prior to providing post-stabilization care services. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
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 post stabilization care. Our reviewer says 
that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a 
Plan facility after the emergency room evaluation on December 28, 2019. There was no documentation 
provided requiring post-stabilization care services from December 28, 2019 through December 30, 2019 at the 
non-Plan facility. Our physician reviewer found the enrollee was hemodynamically stable and appropriate for 
ambulance transport with monitoring to a Plan facility after the emergency room evaluation on 12/28/19. There 
was no documentation provided requiring post-stabilization care services 12/28-12/30/19 at the non-plan 
facility. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for post stabilization care provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three core buildups, including any pins when required 
(D2950 x3). 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service 
is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 three 
core buildups, including any pins when required (D2950 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for irrigation of an implanted venous access 
drug delivery device (96523) performed on March 16, 2020. 
 
You asked the Plan to waive the copayment for irrigation of an implanted venous access drug delivery device. 
You say that irrigation of an implanted venous access drug delivery device should be charged as a preventive 
service. The Plan denied your request. The Plan says the correct copayment was 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 $25 
copayment for a visit to an in-network specialist in an outpatient hospital setting/clinic for Medicare-covered 
non-surgical services.  
 
You have been asked to pay a $25 copayment for irrigation of an implanted venous access drug delivery 
device. Irrigation of an implanted venous access drug delivery device falls within the "Outpatient hospital 
services, non-surgical" 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 irrigation of 
an implanted venous access drug delivery device (96523) performed on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic, tooth #3 (D6245) and 
retainer crown - porcelain/ceramic, teeth #2 and #4 (D6740). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to appeal the denial of the 
services. The multiple crowns are needed for a bridge. The Plan denied your request. The Plan says these 
services are not listed as a covered dental service. 
 
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 
pontic - porcelain/ceramic, tooth #3 (D6245) and retainer crown - porcelain/ceramic, teeth #2 and #4 (D6740).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint fusion surgery.
You asked the Plan to pre-approve the sacroiliac (SI) joint fusion surgery. You say that you are suffering pain and numbness. You say that the requested surgery is medically necessary. The Plan denied your request. The Plan says enough records were submitted to determine medical necessity.
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 sacroiliac (SI) joint fusion surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented SI joint instability, fracture, or lesion. There is no clear documentation that the SI joint is the cause of the enrollee's back pain. 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 sacroiliac (SI) joint fusion surgery. have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint fusion surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided on February 19, 2020 
through March 5, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claims were 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you received services on February 19, 2020. You were not asked to pay a 
copayment for this date of service. Furthermore, review of the file shows that you received a computed 
tomography (CT) scan of the thorax; with contrast material(s) on March 5, 2020. You are asked to pay a $180 
copayment for the CT scan. 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 services provided on 
February 19, 2020 through March 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for emergency services provided on December 16, 2019.
You asked the Plan to reimburse you for the emergency care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the Plan has agreed to reimburse you for $7185.29 for the related request and your Worldwide coverage is limited to $7,500 per calendar year.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. The Plan contract also says that emergency care outside the U.S is limited to $7,500.00 per calendar year. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency care have not been met. Specifically, the record indicates that the Plan has reimbursed you $7,185.29 previously and there is a limit of $7,500.00 for reimbursement for worldwide coverage per year. It is appropriate for the Plan to reimburse you $314.71. Therefore, we decided that the Plan does not have to reimburse you for emergency services provided on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable CPAP machine. 
 
You asked the Plan to pre-approve a portable CPAP machine. You say that you need a portable CPAP machine 
in case the power goes off and to use for travel. The Plan denied your request. The Plan says a duplicate or 
portable CPAP machine used for travel is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP machine. Your CPAP machine serves the same purpose as a portable 
CPAP machine. Therefore, we decided that the Plan does not have to pre-approve a portable CPAP machine.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you appear to not require any specialized therapeutic skills or 
equipment for therapy needs. 
 
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 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. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee is rapidly deteriorating and that 
taking her out of the facility would confuse and frighten her. You say that the enrollee is too weak to participate 
in therapy. The Plan denied your request. The Plan says the enrollee no longer requires daily skilled services. 
The Plan says that the care needed is custodial in nature and is non-covered. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and clear lungs. The enrollee tolerated a regular diet and thin liquids. The 
enrollee received physical therapy and occupational therapy in the skilled nursing facility. By the dates in 
question, the enrollee was at minimal to moderate assist level with functional mobility, including gait up to 100 
feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no 
identifiable skilled nursing needs or skilled therapy needs. The enrollee does not meet the severity of illness or 
intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there is no need 
for daily skilled therapy or nursing needs. 
 
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 physician reviewer 
found that you are walking 225 feet with contact guard assistance, and is at stand-by assist to minimum assist 
for transfers and activities of daily living. You are medically stable. You do not require skilled nursing services 
of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. You do not require skilled therapy services of a qualified therapist required to safely and effectively 
provide medically necessary and reasonable treatment. You do not require skilled nursing or therapy on a daily 
basis. You do not require necessary services 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bladder sling procedure (57287, 57288). 
 
You asked the Plan to pre-approve a bladder sling procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 a bladder sling procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found stress urinary incontinence (SUI) may be treated with a conservative (pelvic floor 
muscle training, incontinence pessaries) or a surgical approach. Candidates for surgical treatment are women 
with SUI who have had unsuccessful conservative treatment. This enrollee has not had an attempt at 
conservative management. Also, she has a significant component of urge incontinence which has not been 
addressed. 
 
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 bladder sling procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bladder sling procedure (57287, 57288).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty group 3 power wheelchair with multiple 
power options. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
enrollee does not have a need for power tilt and recline. 
 
The Plan follows Medicare rules. Medicare rules say that heavy duty power wheelchairs are only covered under 
certain medical indications. 
 
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 requested items. Our physician 
reviewer found that the enrollee has a past medical history of diabetes, hypertension, heart failure and stroke. 
There is no documentation that show that you meet the coverage criteria for power tilt and recline. There is no 
documentation that it is medically necessary for you to have an expandable control system to operate multiple 
power functions. There is no documentation that the requested heavy duty group 3 power wheelchair is 
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 the requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a heavy duty group 3 power wheelchair with multiple power options.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee wants to get back to the state he was 
in before his fall. The Plan denied your request. The Plan says the enrollee does not require daily skilled 
therapy or nursing services on an inpatient basis. 
 
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 physician reviewer 
found that the enrollee has had a decline in function, but is at baseline for mobility using a wheelchair. He is 
alert and oriented appropriately and does not have any acute medical problems. He does not have any parental 
medication, complex wound care or nutrition given via a feeding tube. He is medically stable without any acute 
exacerbations of chronic medical problems. As a practical matter, the enrollee does not require any skilled 
services on an inpatient basis, at a SNF level of care upon discharge from the hospital. Therefore, an admission 
to a SNF for inpatient services is 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography services provided to the enrollee 
on July 22, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95868: 
 
Needle electromyography; cranial nerve supplied muscles, bilateral 
 
CPT 95870: 
 
Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or 
bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation does not indicate that cranial nerve EMG monitoring was performed. The documentation is 
silent as to whether one or both upper extremities was monitored. As such, the documentation does not support 
the billing of CPT 95868 or CPT 95870 x 2. 
 
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 pay for needle electromyography services provided to the enrollee on July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve inpatient services. You say that the enrollee is suicidal. The Plan denied 
your request. The Plan says the enrollee's condition has improved, and he is no longer a threat to self or others. 
 
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 pre-approve inpatient services. Our physician 
reviewer found that active treatment was not taking place. The requested services are not reasonably expected 
or medically necessary to improve your condition, or for the purpose of diagnosis. Based upon review the 
records, you do not meet the criteria for treatment from August 17, 2020, forward, and can be treated in a lesser 
restrictive setting. You are 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.