Persius/hicric huggingface dataset:
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 this is medically necessary. The Plan
denied your request. The Plan says the enrollee has not completed his full course of care in the current 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 the enrollee is currently undergoing acute care hospital (ACH) for chronic
complications following multiple strokes. The enrollee was intubated/ventilated and subsequently received a
tracheotomy. There is no evidence that the enrollee requires services that are not currently available. The
enrollee's long-term prognosis appears to be poor. As LTACHs and ACHs are licensed to provide the same
level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the
current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to
a lower level of care for any ongoing long term care needs.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided
on March 25, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree
with the charges because the services were no different than previous visits. 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 $20
copayment for outpatient rehabilitation services.
You have been asked to pay a $20 copayment for outpatient rehabilitation services. Outpatient rehabilitation
services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health services.
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says you do not
have a plan or intent to harm yourself 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 you presented with a bipolar disorder current episode depressed, alcohol use disorder,
cocaine use disorder, and opiate abuse disorder on Methadone Maintenance. You did not appear to require
inpatient mental health treatment. It does not appear that active treatment was taking place. The services were
not reasonably expected to improve your condition, or for the purpose of diagnosis. Based upon review the
records provided, you were not shown to be a danger to yourself or others. You were 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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve inpatient behavioral health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the provision of INR testing materials rendered from January
22, 2020 to February 12, 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 the services are not covered.
The Plan must follow Medicare rules.
We looked at the file and Medicare rules. The rules say that procedure code G0249 shall not be allowed more
frequently than once every four weeks. The file shows that the Plan previously paid for this code fewer than
four weeks from the date of service at issue. Therefore, we decided that the Plan does not have to pay for the
provision of INR testing materials rendered from January 22, 2020 to February 12, 2020.
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 by an out
of network (OON) provider.
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 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 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
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin.
You asked the Plan to pre-approve Carboplatin. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Carboplatin. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has cervical cancer. The requested use of Carboplatin is not FDA-approved for the
enrollee's diagnosis. The use of Carboplatin is not supported by one of the major drug compendia or by clinical
research that appears in a CMS-approved medical journal. There is no indication for consolidative therapy.
Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Carboplatin have not been met. Therefore, we decided that the Plan does not
have to pre-approve Carboplatin.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on September
20, 2019 and specialist visits (99215) provided on October 9, 2019 and November 12, 2019.
You asked the Plan to waive the copayment for outpatient surgery and specialist visits. You say that you should
not be responsible for these copayments. The Plan denied your request. The Plan says these services were
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 $275
copayment for Medicare-covered outpatient surgery and a $35 copayment for specialist services.
You have been asked to pay $275 for outpatient surgery and $35 for each specialist visit. 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 outpatient surgery provided on September 20, 2019 and specialist
visits (99215) provided on October 9, 2019 and November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95910, CPT 95886) provided on March
26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot
be verified.
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 code 95910 is "Nerve conduction studies; 7-8 studies".
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 use
of CPT code 95910 is not supported by the records provided. Our physician reviewer found that the records did
not include documentation of a nerve conduction study.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT 95910 have not been met.
Additionally, CPT 95886 was not reported with a primary procedure code. CPT 95886 is an add-on code and
must be reported with a primary procedure code for payment to be considered. Therefore, we decided that the
Plan does not have to pay for the services (CPT 95910, CPT 95886) provided on March 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi (durvalumab) treatments.
You asked the Plan to pre-approve the Imnfinzi treatment. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says there is no imaging showing that prior treatment has led to disease
control or whether there has been progression.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Imnfinzi treatment. Our reviewer
says that the available documentation does not support the medical necessity of this treatment at this time. Our
physician reviewer found the enrollee is a female with stage IIIA non-small cell lung cancer with
neuroendocrine features. Treatment with cisplatin and Alimta with radiation was completed on 6/1/2020. In
this case, Imfinzi is FDA approved for treatment of unresectable stage III non-small cell lung cancer in adults
whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy.
However, there is no new imaging submitted to show stable to improved disease after completion of prior
treatment. Without this documented, the use of this drug 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 the Imnfinzi treatment have not been met. Therefore, we decided that the Plan
does not have to pre-approve Imfinzi (durvalumab) treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 11, 2020 by an out-of-network
provider.
You asked the Plan to pay for the dental services. You say that you told the provider that you had dental
insurance. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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.
Review of the file show that you received dental services on March 11, 2020 from an out -of-network provider.
Your contract states, " if you receive services rendered from dentists who do not participate in the supplemental
dental plan network they are not covered benefits. If you receive services from a dentist that does not
participate in the supplemental dental plan network, you will be responsible for the full cost of those services
and no payment will be made by the supplemental dental plan." 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 dental services provided
on March 11, 2020 by an out-of-network provider.
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 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 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 you require services at the LTACH that are
not available at the acute care hospital where you are 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.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the EEG provided on December 27, 2019.
You asked the Plan to pay for the EEG. The Plan denied your request. The Plan says the EEG was 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 pay for the EEG. Our reviewer says that the
requested EEG is not considered medically reasonable and necessary in this case. Our physician reviewer
found that there is not a defined clinical utility for the performance of a limited channel EEG during ACDF (or
most spinal surgeries). EEG is not of diagnostic utility in the prevention of any form of injury to the nervous
system during ACDF. It is otherwise not necessary to perform EEG to evaluate the administration of anesthesia
that is provided during such procedures. Given the lack of diagnostic utility of this service, it cannot be said
that this procedure would reflect the "accepted standards of medical practice for the diagnosis or treatment of
the patient's condition." Rather, provision of such services would otherwise exceed those services necessary for
the proper care of the patient in this case.
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 EEG have not been met. Therefore, we decided that the Plan does not have
to pay for the EEG provided on December 27, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 26, 2019.
You asked the Plan to pay for genetic test. You say that this claim meets the Medicare criteria for coverage.
The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this
provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that
genetic test would not be covered. Under Medicare rules, this means genetic test is considered approved by the
plan. Therefore, we decided that the Plan has to pay for genetic testing provided on November 26, 2019.
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 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 enrollee's care is not complex and does not need a team of
providers.
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 was admitted to an inpatient acute
care facility for management of acute cerebrovascular accident. Her neurologic condition has stabilized and
there are no remaining complex medical conditions which require inpatient management. She does not require
management by a rehabilitation physician at least three days a week. The patient does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. The patient does have a documented need for skilled therapy, including physical and
occupational therapy, but there is no documented need for an intensive, complex interdisciplinary rehabilitation
course. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the geriatric chair purchased on January 29, 2020.
You asked the Plan to reimburse you for the geriatric chair. You say that the Geri chair will help you get to
doctor appointments. The Plan denied your request. The Plan says if suppliers aren't enrolled in Medicare
claims will not be paid and the chair was purchased for use outside the home.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. You did not get prior approval and the Plan requested documentation
supporting medical necessity was not submitted from your physician. The item at issue in this appeal is for use
outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for
use only outside the home. Based on this information, we decided that Medicare rules for coverage of the
geriatric chair have not been met. Therefore, we decided that the Plan does not have to reimburse you for the
geriatric chair purchased on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the
drug testing services provided on August 14, 2019.