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 you need an IRF admission and services. The Plan 
denied your request. The Plan says comprehensive, intensive therapy 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 that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports 
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation 
therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit 
from the 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis provided on January 19, 2019, through November 
16, 2019, by an out-of-area provider. 
 
You asked the Plan to pay for dialysis. You say that the services rendered were medically necessary. The Plan 
denied your request. The Plan says the dialysis services you received from an out-of-network provider at a non-
certified Medicare dialysis facility are not a covered benefit of your health plan contract. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dialysis treatments have not been met. Specifically, services received outside of the United 
States of America (USA) are not covered by Medicare. The Plan has supplemental coverage of emergency and 
urgently needed care received outside of the USA. The dialysis services were not emergent and could have 
been foreseen prior to leaving your service area. This means that the services at issue do not meet Medicare 
guidelines for being urgent in nature. Therefore, we decided that the Plan does not have to pay for dialysis 
provided on January 19, 2019, through November 16, 2019, by an out-of-area provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had on 
July 17, 2020. 
 
You asked the Plan to waive the copayment for the ECG. You say that you were told this test was part of your 
annual physical. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for Medicare-covered tests.  
 
You have been asked to pay a $10 copayment for the ECG. The ECG falls within the Medicare-covered tests 
benefit category. According to your Evidence of Coverage, an annual physical exam only includes the 
following: bodily system examinations, measurement and recording of vital signs, a complete prescription 
medication review, and a review of any recent hospitalizations.  ECGs are not considered part of the annual 
physical exam, so it is appropriate for the Plan to charge a separate copayment for this service. 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 electrocardiogram (ECG) you had on July 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear stress test you had on June 2, 
2020. 
 
You asked the Plan to waive the copayment for the nuclear stress test. You say that you thought you only had a 
$5 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $150 copayment for the nuclear stress test. The nuclear stress test falls within the 
diagnostic and nuclear medicine radiological 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 nuclear stress test you had on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lung function testing you had at an 
outpatient hospital facility on May 6, 2020. 
 
You asked the Plan to waive the coinsurance for the lung function testing. You say that you do not understand 
why this bill was not paid in full. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 20% 
coinsurance for diagnostic procedures and tests.  
 
You have been asked to pay 20% coinsurance for the lung function testing. The lung function testing falls 
within the diagnostic procedures and tests 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 coinsurance 
for the lung function testing you had at an outpatient hospital facility on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on March 4, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this 
copayment. 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 physician/practitioner services/specialist services.  
 
You have been asked to pay $10.36 which is less than your copayment amount of a $20 copayment for 
specialist services. Specialist services were provided; therefore, the correct copayment has been applied. 
Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on 
March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 19, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test requires the use of CPT 81479. 
 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 13, 
2020 and May 20, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the submitted taxonomy corresponds to Registered 
Nurse Wound Care which is not recognized as payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Original Medicare does not allow all 
professionals to directly submit charges for the services that they provide. 
 
Data.CMS.gov, Crosswalk Medicare Provider/ Supplier to Healthcare Provider Taxonomy does not show the 
taxonomy submitted, Registered Nurse Wound Care, as eligible for Medicare payment. Based on this 
information, we decided that Medicare rules for coverage of the subsequent nursing facility care have not been 
met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided 
on May 13, 2020 and May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an acute inpatient rehabilitation facility 
(IRF) for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are 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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care at this time. The enrollee is reasonably expected to be able to fully participate in and benefit 
from the 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 admission to an acute inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive vascular study. 
 
 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of lower extremity ischemia, neurological symptoms, or signs 
or symptoms of altered blood flow. 
 
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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records did not show clear signs of lower extremity ischemia, neurological symptoms, or 
altered blood flow to justify this arterial testing. It was noted that the cellulitis was improving with treatment. 
No claudication, low pulse strength, abnormal ABI, or any cranial signs of poor arterial flow were noted. 
Therefore, this request for Duplex and physiologic artery testing is not justified and you do not meet criteria. 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a non-invasive vascular study.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis you had on July 28, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that there is a billing discrepancy on this 
bill. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the diagnostic and 
nuclear medicine radiological 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 computed tomography (CT) scan of the abdomen and pelvis you had on July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (85027, 80053, 80061, 83036, 84443, 
and 36415) provided on July 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you were not aware you had to use a certain 
lab. The Plan denied your request. The Plan says you did not use your designated site for laboratory services. 
 
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 your PCP's designated site. 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 laboratory services (85027, 80053, 80061, 
83036, 84443, and 36415) provided on July 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3348) provided on 
May 27, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were in a lot of pain. You say that you were 
not aware that the provider was out of network. The Plan denied your request. The Plan says the retreatment of 
a previous root canal is not listed as a covered 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 dental service you received is not 
among those covered under this benefit, regardless of the dental provider's network status. Therefore, we 
decided that the Plan does not have to pay for the retreatment of a previous root canal (D3348) provided on 
May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the preventive dental service (D1999), the 
immediate partial denture (D5820), the implant (D6010), bone graft at time of implant placement (D6104), and 
the extraction (D7140) provided on August 18, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you paid for the services out of 
pocket. You say that the Plan rejected payment to you because the provider does not participate with the Plan. 
The Plan denied your request. The Plan says the dental provider in this case is not a network provider. The Plan 
says that dental services you receive out of network are not covered. The Plan also says that you are 
responsible for dental services you receive out of network. 
 
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 provider in this case is not a 
network provider. The Summary of Dental Benefits clearly states that you are responsible for dental services 
that you receive out of network. Therefore, we decided that the Plan does not have to reimburse you for the 
preventive dental service (D1999), the immediate partial denture (D5820), the implant (D6010), bone graft at 
time of implant placement (D6104), and the extraction (D7140) provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) and filling (D2393) provided on July 
16, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services you received are standard. You also 
say that you were not aware that the services would not be covered. You also say that you cannot afford to pay 
for these services. The Plan denied your request. The Plan says the extraction is not listed as a covered service. 
The Plan says the filling is not listed as a covered 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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction (D7140) and filling (D2393) provided on July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve Tecentriq. You say that the enrollee has a relatively high expression of 
PDL1. The Plan denied your request. The Plan says the use of this drug alone is not supported for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Tecentriq. Our physician reviewer 
found that the enrollee has PDL1 positive metastatic breast cancer. The use of the requested drug is not FDA-
approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia 
or by clinical research that appears in a CMS-approved medical journal. The documentation support that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not finished treatment in the hospital. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital and when considered medically stable 
by the treating team will be an appropriate candidate for care at a less intense level such as a skilled nursing 
facility. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where the enrollee is currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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.