Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services provided on March 14, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 rest home visit services provided on March 14, 
2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility 
(IRF) admission and services provided from February 15, 2020 to February 28, 2020. 
 
You asked the Plan to waive the copayment for the IRF care. The Plan denied your request. The Plan says that 
the claim processed 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 $300 
copay per day for days 1-5 of Inpatient hospital care.  
 
You have been asked to pay a $300 copay for the IRF care. The IRF care falls within the days 1-5 of Inpatient 
hospital care 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 acute inpatient 
rehabilitation facility (IRF) admission and services provided from February 15, 2020 to February 28, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on April 29, 
2019. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were informed that your 
doctor was no longer in-network and you ended up going to the emergency room which caused you to have a 
higher copayment. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided on 
April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on January 
16, 2020. 
 
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was 
medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate 
the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the enrollee in accordance 
with Medicare policies.  
 
The medical records do not mention or support medical necessity for the orthosis. Therefore, we decided that 
the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tracheotomy tube change prior to establishment of fistula 
tract services coded 31502 provided on March 9, 2020. 
 
You asked the Plan to pay for the tracheotomy tube change prior to establishment of fistula tract services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 CPT code 31502 is not supported in the medical record. Specifically, this code was billed with 
place of service 11 (office). This procedure code should never be performed in the place of service 11. Based 
on this information, we decided that Medicare rules for coverage of the tracheotomy tube change prior to 
establishment of fistula tract services have not been met. Therefore, we decided that the Plan does not have to 
pay for the tracheotomy tube change prior to establishment of fistula tract services coded 31502 provided on 
March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from December 12, 2019 to 
December 16, 2019. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that 
there is no valid referral for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Masters of Social Work (MSW) is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue is a Masters of Social Work.  A Masters of 
Social Work is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not 
have to pay for psychotherapy services provided from December 12, 2019 to December 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an X-Ray examination provided on May 
13, 2020. 
 
You asked the Plan to waive the copayment for X-Ray exam. You say that the provider did not perform this X-
Ray correctly, so you should not have to pay a copayment. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 
copayment for X-Ray exam.  
 
You have been asked to pay $20 copayment for X-Ray exam. X-Ray exam 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 an X-Ray examination provided on May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mammography provided on February 
25, 2020. 
 
You asked the Plan to waive the copayment for the mammography. You say that you should not have to pay for 
this. The Plan denied your request. The Plan says that the claim paid correctly according to the your plan 
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). Your contract with the Plan clearly says that you must pay a $70 
copayment for diagnostic mammography at an outpatient hospital.  
 
You have been asked to pay a $70 copayment for the mammography. The mammography falls within the 
diagnostic mammography at an outpatient hospital 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 mammography provided on February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visudyne (J3396). 
 
You asked the Plan to pre-approve Visudyne. You say that Visudyne is medically necessary. The Plan denied 
your request. The Plan says a trial of bevacizumab is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Visudyne. Our reviewer says that 
Visudyne is not medically necessary. Our physician reviewer found the record does not show that the enrollee 
trialed the plan preferred drug or that the plan preferred drug would be unsafe or ineffective 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 Visudyne have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visudyne (J3396).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on February 17, 2020. 
 
You asked the Plan to pay for the crown. You say that the unclear disclosures in the Plan documents led you to 
believe the crown would be covered. The Plan denied your request. The Plan says this service is not a covered 
benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) provided on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dulera inhaler (J3535). 
 
You asked the Plan to pre-approve a Dulera inhaler. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of your prescription drug plan. 
 
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 a Dulera inhaler (J3535).  
 
Benefits for a Dulera inhaler 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: 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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 enrollee required minimum assistance to walk 90 feet with a rolling walker. The 
enrollee required stand-by assistance to minimum assistance with transfers and activities of daily living. The 
enrollee is medically stable. The documentation does not support that the enrollee requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee does require physical 
and occupational therapy, the documentation does not support that the enrollee requires an intensive inpatient 
rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 enrollee required maximum assistance with two people to walk one foot. The 
enrollee required moderate to maximum assistance with transfers and activities of daily living. The enrollee is 
medically stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. While the enrollee does require additional physical 
therapy and occupational therapy, the enrollee does not require an intensive inpatient rehabilitation therapy 
program. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar vertiflex interspinous and/or interlaminar 
device. 
 
You asked the Plan to pre-approve lumbar vertiflex interspinous and/or interlaminar device. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are not medically necessary. 
 
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 lumbar vertiflex interspinous and/or 
interlaminar device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain. The 
documentation does not support spinal instability. The requested procedure and devices remains experimental 
for use in spinal surgery. More research is need to show safety and efficacy. Therefore, the enrollee does not 
meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar vertiflex interspinous and/or interlaminar device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar vertiflex interspinous and/or 
interlaminar device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a partial hospitalization program. 
 
You asked the Plan to pre-approve partial hospitalization program. You say that you are appealing based on 
medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the enrollee does not need this level of care and can be treated at an outpatient level. 
 
The Plan follows Medicare rules. Medicare rules say that enrollees may qualify for a partial hospitalization 
program if certain clinical criteria are met. 
 
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 partial hospitalization program. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested partial hospitalization 
program. Our physician reviewer found in terms of risk of harm, the records support a score of 1 due to a lack 
of current suicidal ideation with no self-harm behaviors. With regards to functional status, the records support a 
score of 1 due to lack of problems with comorbidity. In terms of medical, addictive, and psychiatric 
comorbidity, the records support a score of 1 due to overall medical stability. In terms of level of stress of the 
recovery environment, the records support a score of 1 due to a stable living situation. With regards to level of 
support for the recovery environment, the records support a score of 1 due to availability of treatment 
resources. With regards to treatment and recovery history, the records support a score of 2 to 3 due to recent 
success at the partial hospital level of care. In terms of engagement and recovery status, the records support a 
score of 1 due to cooperation in treatment and insight into his need for treatment along with insight into 
treatment needs. Thus, the enrollee has a composite score of 7 to 9. This means treatment in a community-
based outpatient clinic setting is appropriate. Therefore, the requested partial hospitalization program is not 
medically necessary for the treatment of the 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 partial hospitalization program have not been met. Therefore, we decided that 
the Plan does not have to pre-approve admission to a partial hospitalization program.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, the lumbar-sacral 
orthosis, the shoulder-elbow-wrist-hand orthosis, the wrist hand orthosis, heel stabilizer, or wrist hand orthosis 
provided on March 12, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397), the lumbar-sacral 
orthosis (L0650), the shoulder-elbow-wrist-hand orthosis (L3960), the wrist hand orthosis (L3916), heel 
stabilizer (L3170), or wrist hand orthosis (L3916). You say that the Plan should pay this claim.  
The Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The supplier should also have on file any documentation containing a 
description of the item delivered to the beneficiary to determine the accuracy of claims coding including, but 
not limited to, a voucher, invoice or statement in the supplier records.   
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The shipping date 
and the claim date show a significant variation. The invoice does not indicate the specific supplies. Therefore, 
we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, the lumbar-sacral 
orthosis, the shoulder-elbow-wrist-hand orthosis, the wrist hand orthosis, heel stabilizer, or wrist hand orthosis 
provided on March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve 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 pre-approve 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 as the enrollee did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. 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 as the enrollee did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our doctor was unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to themselves or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations.
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 pre-approve inpatient mental health care.