Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing 
or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit (99214) on June 15, 
2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you were denied access to 
your primary care doctor because of lockdown involving the coronavirus. The Plan denied your request. The 
Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each visit for urgently needed services. The Plan has waived select copayments but copayments 
for urgently needed services are not eligible for the waiver. 
 
You have been asked to pay a $20 copayment for an urgent care visit. An urgent care visit falls within the 
"Urgently Needed 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 an urgent 
care visit (99214) on June 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 15, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not request to be 
transferred via ambulance to the rehabilitation facility. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received ambulance services on June 15, 2020. You are asked to pay a $200 
copayment for the ambulance services. Your EOC states that enrollees must pay a $200 copayment for each 
one-way Medicare-covered ground trip. 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 ambulance 
services provided on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMs device (CPT Codes: 33289 and 
C2624). 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that the member has had multiple 
hospitalizations due to heart failure. The Plan denied your request. The Plan says the notes do not show that the 
member has been enrolled in an approved category B investigational device exemption (IDE) study. 
 
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 
CardioMEMs device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found in this circumstance; therapy change based 
on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial 
to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been 
raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the 
CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current 
guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device should still 
be considered experimental or investigational. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the CardioMEMs device (CPT Codes: 33289 and C2624).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular risk assessment panel provided to the 
enrollee on May 12, 2020. 
 
You asked the Plan to pay for the testing. You say that  The Plan denied your request. The Plan says Medicare 
denies coverage for all cardiovascular risk assessment panels. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that CPT code 81493 - Coronary artery disease, mRNA, gene 
expression profiling by real-time RT-PCR of 23 genes - is/was medically reasonable and necessary for the 
enrollee in this case. The enrollee is a 60-year-old woman who was evaluated on 5/12/20 to establish primary 
care services. The enrollee's primary concerns were med refills and Covid-19 testing. The enrollee voiced no 
other concerns. The physical exam was unremarkable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a cardiovascular risk assessment panel provided to the enrollee on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the out-of-network dental services. 
 
You asked the Plan to pre-approve the out of network dental services. You say that there are no in network 
dentists in your area. You also say that traveling over 20 miles is a hardship for you. The Plan denied your 
request. The Plan says there are in network providers who can provide this service. The Plan says that dental 
services are not covered when you go 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, out of network dental services are not 
covered. Therefore, we decided that the Plan does not have to pre-approve the out-of-network dental 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 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 member's appropriate therapy needs are not precluded in an 
alternate level of care such as skilled nursing facility. 
 
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 does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient is currently residing in skilled nursing 
facility after a prolonged acute care hospitalization for pneumonia, respiratory failure and renal failure. Therapy 
services are being provided. The enrollee's medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated post and core in addition to a crown 
(D2954). 
 
You asked the Plan to pre-approve the dental service. You say that you need a bridge for your missing teeth. 
You say that you do not understand why the crowns were approved but the bridge was not. The Plan denied 
your request. The Plan says prefabricated post and core in addition to a crown 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
prefabricated post and core in addition to a crown (D2954).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection, abatacept, 10 mg (J0129) 
chemotherapy intravenous infusion (96413) infusion, normal saline solution, 250 cc (J7050) therapeutic, 
prophylactic, or diagnostic injection (specify substance or drug) (96372) provided June 22, 2020 to July 21, 
2020. 
 
You asked the Plan to waive the copayment for the infusion services. You say that you received the same exact 
medications for all 3 infusions and how they were administered. Why such a difference in charge if they are 
exactly the same. The Plan denied your request. The Plan says the claim processed and the correct copayment 
was applied per the Evidence of Coverage. 
 
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 each Medicare covered Part B drug for Medicare Part B prescription drugs.  
 
You have been asked to pay $2,528.92 ($906.07 + $747.03 + $875.83) for the infusion services. The reason 
there is a difference in the cost sharing amounts on the 3 claims is due to the additional Part B drugs that were 
used on some visits. The infusion services fall within the Medicare Part B prescription drugs 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 injection, abatacept, 10 mg (J0129) chemotherapy 
intravenous infusion (96413) infusion, normal saline solution, 250 cc (J7050) therapeutic, prophylactic, or 
diagnostic injection (specify substance or drug) (96372) provided June 22, 2020 to July 21, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient physician services provided on March 19, 2020 and March 
20, 2020 
 
You asked the Plan to pay for the inpatient physician services (99223, (99232). You say that the Plan should 
pay this claim. The Plan denied your request. The Plan says that the services denied for 
precertification/notification/authorization/pre-treatment exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not done their due diligence in explaining the denial of two of the 
four dates of service. Therefore, we decided that the Plan has to pay for the inpatient physician services 
provided on March 19, 2020 and March 20, 2020  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on July 14, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered as it helped your back 
pain. The Plan denied your request. The Plan says this service was not related to manual manipulation of the 
spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
care provided on July 14, 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 your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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 ds 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 conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation 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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 23, 2020, to 
September 26, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that inpatient care was not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan has to pay for the acute inpatient hospital care provided from September 23, 2020, to September 26, 
2020.  
 
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 admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
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 services could be provided in another setting. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for adjacent tissue transfer or rearrangement of the trunk (CPT 14001) 
provided to the enrollee on March 9, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that procedure code 14001 is not supported by the medical records submitted. 
 
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 14001 is "adjacent tissue transfer or rearrangement of the trunk, for defects 10.1 sq cm to 30.0 sq cm." 
 
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 reviewers say that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
documentation with the addendum supports the performance and billing of CPT 14001 (adjacent tissue transfer 
or rearrangement of the trunk, for defects 10.1 sq cm to 30.0 sq cm). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
adjacent tissue transfer or rearrangement of the trunk (CPT 14001) provided to the enrollee on March 9, 2020. 
  
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.