Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a 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. Our 
physician reviewer found 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 
surgical repair of a hip fracture after a fall. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 30, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you have 
an HMO plan with limited out-of-network coverage. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on May 4, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior 
authorization was not obtained. 
 
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 specialist services provided on May 4, 2020, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ileostomy supplies to be provided by the out-of-network 
provider. 
 
You asked the Plan to pre-approve the ileostomy supplies. The Plan denied your request. The Plan says the 
Plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's 
(PCP) specialty 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve ileostomy 
supplies to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 28, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD) for the enrollee. 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show bronchiectasis as shown on CT scan, cystic fibrosis, or a 
neuromuscular disease. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 a HFCWOD. Our reviewer says that the 
requested device is not medically reasonable or necessary. Our physician reviewer found a chest CT from does not mention bronchiectasis in the report. The physician's hand-written note. 
indicates the CT "confirms bronchiectasis", but does not mention important details of the type of 
bronchiectasis, the location, or the severity. Thus the diagnosis of bronchiectasis is not convincingly 
established. The enrollee does not have cystic fibrosis or a neuromuscular disease. The enrollee has a diganosis 
of COPD. HFCWO has not been shown to be effective in the treatment of COPD, and is therefore considered 
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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) services. 
 
You asked the Plan to pre-approve the HBOT services. You say that the requested HBOT is medically 
necessary and that, without the treatments requested, her hearing may not return. The Plan denied your request. 
The Plan says HBOT is not covered for the enrollee's condition. 
 
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 HBOT services. Our reviewer says 
that HBOT services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a diagnosis of sensorineural hearing loss. Our physician reviewer found that the 
guidelines do not support the use of HBOT for the enrollee's condition. 
 
 
 
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 HBOT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hyperbaric oxygen therapy (HBOT) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial hospitalization mental health services. 
 
You asked the Plan to pre-approve the partial hospitalization mental health services.. You say that the services 
are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the partial hospitalization mental health 
services. Our reviewer says that the partial hospitalization mental health services are not medically necessary. 
Our physician reviewer found this patient did not have an imminent risk to herself or others. The enrollee could 
receive treatment in a community-based outpatient clinic 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 the partial hospitalization mental health services. have not been met. Therefore, 
we decided that the Plan does not have to pre-approve partial hospitalization mental health 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services 
but does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the 
enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
Care at the skilled nursing facility level appears to be more appropriate 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 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 inpatient hospital care billed with unspecified severe protein-calorie 
malnutrition (E43) provided from September 27, 2018, to October 1, 2018. 
 
You asked the Plan to pay for inpatient hospital care. You say that the secondary diagnosis was billed correctly 
based on the medical records. The Plan denied your request. The Plan says that the medical records do not 
support the secondary diagnosis as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. DRG 592 is defined as skin ulcers 
with major complication or comorbidity. 
 
In this case, you billed the services provided from September 27, 2018, to October 1, 2018, with DRG 592. 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 inpatient hospital care. Our reviewer says 
that the records support the diagnosis unspecified severe protein-calorie malnutrition (E43). Our physician 
reviewer found the patient was clearly severely malnourished as they were underweight, with poor oral intake. 
Therefore, they meet the criteria for severe protein calorie malnutrition 
 
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 hospital care have been met. Therefore, we decided that the Plan has to 
pay for inpatient hospital care billed with unspecified severe protein-calorie malnutrition (E43) provided from 
September 27, 2018, to October 1, 2018. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the intraoral complete series x-ray (D0210), 
prophylaxis (D1110), and the comprehensive oral evaluation (D0150) provided on September 1, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you were advised by the dental office 
that they accepted your plan. You say that you paid full price for the services. You also say that you found out 
a lot about "in network" places like this. The Plan denied your request. The Plan says the intraoral complete 
series x-ray is not listed as a covered service. The Plan says that the provider in this case is out of network. The 
Plan also says that you pay a 50% coinsurance for dental services that you receive out of network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral complete series x-ray is 
not among those covered under this benefit. The Evidence of Coverage clearly shows there is a 50% 
coinsurance for dental services that you receive out of network. Additionally, you may be billed by the out of 
network provider for any amount greater than the payment made by the Plan to the provider. Therefore, we 
decided that the Plan does not have to reimburse you for the intraoral complete series x-ray (D0210), 
prophylaxis (D1110), and the comprehensive oral evaluation (D0150) provided on September 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require daily skilled therapy and has no daily 
skilled medical needs. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on May 4, 2020, to September 
15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan 
says that there is no referring provider listed. 
 
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 physician services provided on May 4, 2020, to 
September 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and the x-ray 
provided on July 17, 2020. 
 
You asked the Plan to waive the copayments for the specialist office visits and the x-ray. You say that you 
would like the Plan to pay the $54 copayment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $40 
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a 
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office 
and a $14 copayment for each in-network Medicare-covered standard x-ray.  
 
You have been asked to pay a $40 copayment for the specialist office visit and a $14 copayment for the x-ray. 
The specialist office visit falls within the 'Physician/Practitioner Services, Including Doctor's Office Visits' 
benefit category. The x-ray 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 copayments for the specialist office visit and the x-ray provided on July 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on July 29, 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 July 29, 2020 
by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee is continuing to make progress 
and his stay should be extended. The Plan denied your request. The Plan says SNF care 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs. The enrollee received physical therapy, speech therapy, and 
occupational therapy in the SNF. By the dates in question, the enrollee was at a supervision to contact guard 
assist level with functional mobility, including gait to 110 feet with a hemi walker. The enrollee required 
varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are 
no identifiable skilled therapy service needs. The enrollee does not meet the 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuation of skilled nursing facility (SNF) services.