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 these services are medically necessary. The Plan 
denied your request. The Plan says that you could be cared for in a skilled nursing facility or home with help. 
 
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 does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and hyperglycemia. 
Your medical problems are stable. There are no identified problems that need inpatient medical management. 
There are no complex nursing or rehabilitation needs. 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. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on April 18, 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 Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid 
panel, for symptomatic patients with suspected or documented cardiovascular disease. 
 
The Plan must follow Medicare rules. Medicare rules say that cardiovascular risk assessment testing is not 
covered. 
 
The testing at issue in this case is statutorily not covered by Medicare. 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 cardiovascular risk assessment testing provided to the enrollee on April 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on July 7, 2020 by an OON provider. 
 
You asked the Plan to pay for the extraction. You say that you went to this provider after two failed attempts to 
have the service rendered by an in-network provider. You also say that the in-network providers were not able 
to perform the service. The Plan denied your request. The Plan says the service was rendered by an OON 
provider. The Plan also says that dental services performed by an oral surgeon or OON providers are not 
covered. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
extraction provided on July 7, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of prostate 
cancer. The use of proton beam therapy is not routinely recommended outside of a prospective clinical trial or 
registry. There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage 
over other forms of definitive radiation therapy. The use of proton beam therapy is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services you received from 
June 25, 2020, to July 20, 2020. 
 
You asked the Plan to waive the copayments for the chiropractic services. You say that you were told that all 
copayments would be paid by your Plan until the end of the year. The Plan denied your request. The Plan says 
you were charged these copayments 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 $20 
copayment per visit for chiropractic services.  
 
You have been asked to pay a $20 copayment per visit for the chiropractic services. There is no provision in 
your contract for a waiver of these copayments. 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 copayments for 
chiropractic services you received from June 25, 2020, to July 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 43262) provided on January 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed 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 43262 is "Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy".We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the user of CPT code 43262 is not supported by the records provided. Our coding reviewer found that the procedure report does not include enough detail to confirm this procedure was performed.We looked at this coder'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 doesnot have to pay forthe services (CPT 43262) provided on January 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on June 19, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 physician services provided on June 19, 2020 
by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transthoracic Echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve TTE. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no change in cardiac status to support this test. 
 
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 TTE. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records show that there has been no change in the enrollee's clinical status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Transthoracic Echocardiography (TTE) (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula (B4150) provided December 10, 2019. 
 
You asked the Plan to pay for the enteral formula. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the documentation submitted did not include a valid physician order. 
 
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 record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for enteral formula (B4150) provided December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with X-ray of pelvis (99213, 72190) provided 
on June 9, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with X-ray of pelvis. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 office visit with X-ray of pelvis (99213, 
72190) provided on June 9, 2020, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve these services. You say that you need more PT. The Plan denied your 
request. The Plan says two visits are approved and eight further are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found the requested additional therapy is not generally accepted as specific and 
effective therapy for your condition. You have had extensive therapy for this condition and it does not appear 
that you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, 
that the services can be safely and effectively performed only by a therapist, or under the supervision of a 
therapist. You have been authorized additional sessions to review an independent exercise program. The 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight additional physical therapy (PT) sessions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on June 17, 2020, to June 20, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you think you are being over charged. 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 $350 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital stays. 

You have been asked to pay a $350 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $1,050 ($350 x 3 days = $1,050). An inpatient hospital stay falls within the inpatient hospital stays 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 inpatient hospital stay provided by a participating provider on June 17, 2020, to June 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the referring provider is also out-of-network. 
 
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 an office visit provided on January 20, 2020 by an 
out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 15, 2020, to July 23, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were referred by a participating 
provider. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the referring provider is also out-of-network. 
 
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 physical therapy provided on June 15, 2020, to 
July 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) straight knee joint, heavy duty 
(L2385) lower extremity suspension sleeve (L2397) provided April 8, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of 
the services in dispute. The Plan denied your request. The Plan says the records do not support the billed 
service. 
 
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 record does not contain a valid physician's order and an itemized shipping/billing invoice to indicate the 
specific supplies for the billed date of service. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
knee orthosis (L1851) straight knee joint, heavy duty (L2385) lower extremity suspension sleeve (L2397) 
provided April 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
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 can safely receive the services you need in other settings. 
 
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 were admitted for surgical repair of a hip fracture 
after a fall. Your medical problems are stable. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. 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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 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 you appear to be improving but requires additional short term acute care services of 
less than twenty-five (25) days, which can be safely completed at the current facility. You do not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that you require that are not already available and covered at the current facility. Therefore, this request for 
LTACH services will be considered not medically necessary. Transfer to a lower level of care may be 
considered when treatment has completed. 
 
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 LTACH services.