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

We decided that the Plan does not have to pre-approve surgery to be performed by an out-of-network provider. 
 
You asked the Plan to pre-approve the surgery. You say that you need this surgery because you are 
experiencing sleeping difficulty due to an increase throbbing pain of your left hand. The Plan denied your 
request. The Plan says there are in-network providers that can provide the services. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgery to be performed by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, preventive procedure, 
first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on June 22, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, preventive procedure, and intraoral periapical 
x-rays. The Plan denied your request. The Plan says these services were rendered by an OON provider. The 
Plan also says that no benefits are available for procedures performed by OON providers. 
 
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 
comprehensive oral evaluation, preventive procedure, first intraoral periapical x-ray, and additional intraoral 
periapical x-ray provided on June 22, 2020 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four home health physical and occupational therapy 
visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the skills of a licensed therapist are no longer needed. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found you appear to have 
reached a plateau in therapy, and there is no documented need for ongoing in-home skilled therapy. Your care 
needs at this point are custodial, and can be provided at a lower level of care, such as private aides or long term 
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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve four home health physical and occupational therapy visits.
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 could be safely received in a different setting, for example: in a skilled 
nursing facility, or home with home health services. 
 
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 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's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires an 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 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 review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission. You are generally medically stable after a subarachnoid hemorrhage with debility with 
no evidence of medical or nursing needs in an IRF and your current functional status does not require IRF level 
of therapies. There is no evidence of medical issues that require monitoring by an inpatient rehab physician 
three (3) times a week. The documentation does not support that there is a need for an intensive therapy 
program with 3 hours a day at current level of function (see PT note dated October 12, 2020) and an 
interdisciplinary approach to rehab care. The IRF admission is not medically necessary, and also does not meet 
the CMS coverage criteria. Your rehab needs can be safely and effectively met in an alternate, less intense 
setting such as in a skilled nursing facility (SNF) or in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing rendered on January 29, 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 procedure code G0481 is not supported. 
 
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 G0481 is definitive drug testing, 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation 
of testing of 8-14 drug classes. 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 pay for the definitive drug 
testing rendered on January 29, 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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for surgical repair of a hip fracture after a fall. The 
documentation supports that the enrollee's medical problems are stable. The documentation supports the need 
for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that you require 
additional routine transportation miles to attend medical appointments. The Plan denied your request. The Plan 
says this is not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on our research, your provider is 98 miles from your home address. This exceeds the one-way trip limit by 
48 miles. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation 
mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; second level (CPT Code 22870), interspinous process distraction device (implantable) 
(CPT Code C1821) and insertion of interlaminar/interspinous process stabilization/distraction device, without 
open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 
22869). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve (CPT Code 22870), (CPT Code C1821) and (CPT Code 22869).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on August 21, 2019. 
 
You asked the Plan to pay for the home visit. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says the medical records show the services were performed by an LVN and billed by a 
physician. 
 
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 99348 is home visit for the evaluation and management 
of an established patient. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, there is no documentation 
that a physician was present during the home visit. Based on this information, we decided that Medicare rules 
for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for 
the home visit provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four additional resin-based composites provided on June 
10, 2020. 
 
You asked the Plan to pay for the four additional resin-based composites. You say that you were informed they 
dentist accepted your insurance. You say that you would have made sure you went to the right place if you 
knew the dentist was out-of-network. The Plan denied your request. The Plan says the claim reprocessed to 
reflect your in-network benefits as a one-time exception. 
 
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, you also have a maximum benefit of 2 
amalgam or composite restorations per calendar year. The Plan paid for 2 resin-based composites provided on 
June 10, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the 
four additional resin-based composites provided on June 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99334) provided from June 17, 2020. 
 
You asked the Plan to pay for a rest home visit. You say that you believe the enrollee's hospice benefit had 
ended. The Plan denied your request. The Plan says payment for this service is the responsibility of Original 
Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a rest home visit (99334) provided from June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided on 
April 4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. 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 subsequent nursing facility visit (99308) 
provided on April 4, 2020, by an out of network (OON) provider.
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 based on the documentation provided, the 
enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The 
enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a 
practical matter, can be provided at a lower level of care (ex. outpatient therapy, HHS, AL, LTC). 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that Keytruda is 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 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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found the requested use of Keytruda is not FDA 
approved. The requested use is not supported in any of the CMS approved compendia. The reviewing physician 
did not find any supportive citations in the medical literature for this use of Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99053) provided on July 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that The rules state that a status indicator of "B" 
under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment 
for other services not specified.  
 
We looked at the file and Medicare rules. Procedure code 99053 is assigned a status indicator of ?B? under the 
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into 
payment for other services. No separate payment can be made for these services. 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 services (CPT 99053) provided on July 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require close supervision by a rehab physician, or at least three hours per day of therapy. 
 
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 physician reviewer found 
that your current level of function is walking with contact guard to minimal assist, transfers and grooming with 
contact guard assist, and lower body dressing with standby assist. The complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight 
only in an IRF. You may benefit from physical and occupational therapy, but the documentation does not 
support that your functional status requires an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. 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 the medical services provided to you by an out-of-network provider on June 
1, 2020.