Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on February 24, 2020. 
 
You asked the Plan to pay for the core buildup. You say that according to your Evidence of Coverage, balance 
billing is not allowed. You also say that you did not have any desire to receive services that were not covered. 
The Plan denied your request. The Plan says this service is not covered by your dental plan. 
 
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 pay for the core 
buildup, including any pins when required (D2950) provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and the chronic 
care management services (99490) rendered by the out of network (OON) provider on March 6, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 domiciliary or rest home visit (99336) and the chronic care management services 
(99490) rendered by the out of network (OON) provider on March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 14, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code should be entered adjacent to the code in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 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 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 you are medically stable with Debility with no evidence of complex medical issues 
that require monitoring by an inpatient physical, medicine, and rehabilitation (PMR) physician three times per 
week or need for acute rehab nursing care. While you may benefit from continuing physical therapy (PT) and 
occupational therapy (OT), there is no evidence of need for an intensive therapy program at current functional 
level with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to 
rehabilitation care. Admission to IRF is not medically necessary based on lack of medical complexity and 
current functional status of minimal to contact guard assist for mobility. Your rehab needs can be met at an 
alternate, low intensity level setting such as an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of continuing objective improvement. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the additional requested skilled physical therapy 
services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's 
level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function 
and/or prevent deterioration. The enrollee appears to have plateaued with physical therapy with unchanged 
balance and endurance assessments and further improvement with physical therapy does not appear likely. 
 
 
 
 
 
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 home health physical therapy services for the enrollee.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve total knee replacement. We decided that the Plan does not have to 
pre-approve inpatient admission.  
 
You asked the Plan to pre-approve total knee replacement with inpatient admission. You say that you would 
like reconsideration because the member has not smoked since surgery in November of 2019. The Plan says 
that medical studies show that this surgery has better results for those who do not smoke. 
We decided that the Plan has to pre-approve total knee replacement. 
 
The Plan follows Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
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 total knee replacement with inpatient 
admission. Our reviewer says that current evidence based medical literature would support total knee 
arthroplasty. The most recent tobacco screen in the medical records is dated December 4, 2018. The enrollee 
reports she successfully quit smoking prior to cervical fusion surgery and remains non-smoking.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total knee replacement have been met. Therefore, we decided that the Plan has 
to pre-approve total knee replacement. 
 
We also decided that the Plan does not have to pre-approve inpatient admission. 
 
The Plan follows Medicare rules. Medicare rules say that that an inpatient admission is generally appropriate 
when the admitting physician expects the patient to need hospital care that crosses at least two midnights. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient admission. Our physician 
reviewer found there is no specific indication submitted by the orthopedic surgeon to support the medical 
necessity of inpatient admission. There is no evidence that her comorbidities are not under control. There is no 
documentation in the record showing that the admitting physician reasonably expects that the member?s 
necessary hospital care will 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission. 
 
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 the office visits (99213) rendered by the out of network 
(OON) provider on September 13, 2019 and October 16, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 office visits (99213) rendered by the out of network (OON) provider on  
September 13, 2019 and October 16, 2019.
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 you stabilized medically and are ready for 
discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. 
You are medically stable and can receive further rehab services at a lower level of care. Although further rehab 
services would be appropriate to improve function and strength, as a practical matter, the daily skilled services 
can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or ventilator support. You have a feeding tube that is chronic and you manage 
this be yourself mostly. You are medically stable without any acute exacerbations of chronic medical problems. 
Your physical function is at or near your baseline and you can receive services at a lower level of care. 
Admission to a SNF for inpatient skilled rehab services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic surgery consultations to be provided at the 
tertiary level of care. 
 
You asked the Plan to pre-approve specialist visits. You say that this doctor has 28 years of experience, you 
have seen him in the past, and this facility has a good reputation. The Plan denied your request. The Plan says 
the denial of authorization for this service is correct, because you do not need to be treated at the tertiary level 
of care and can be treated by a community-level plastic surgeon. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 specialist visits. Our reviewer says that 
you do not meet the Medicare criteria for treatment at the tertiary level of care. Our physician reviewer found 
the Plan's denial is medically justified on the basis that it is offering adequate care to meet your medical needs 
through referral to a community-level specialist. The documentation does not identify a condition that would 
make it medically necessary for you to see a tertiary level of care provider. The Plan has non-tertiary providers 
who meet the standards of care required for treatment of your 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 specialist visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve plastic surgery consultations to be provided at the tertiary level of care.
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 reconsideration because these 
services are medically necessary. The Plan denied your request. The Plan says the member's care can be 
provided in 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. Our 
physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your 
care needs can be met at a lower level of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing care provided on April 7, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for skilled nursing care. You say that these services were provided in a skilled 
nursing facility setting. You say that it is the facility's responsibility to obtain prior authorization. The Plan 
denied your request. The Plan says prior authorization was not obtained by the facility or the provider; 
therefore, payment for these services have 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 skilled nursing care provided on April 7, 2020 by 
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
March 7, 2020 to March 10, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not ask to go to 
the hospital and feel the charges are too high. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 
copayment for days 1-4 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 7, 2020 to March 10, 2020. Therefore, you are responsible to 
pay a $395 copayment for days 1-4 (March 7, 2020 to March 9, 2020). $395 (copayment) x 3 (inpatient days) = 
$1,185.  
 
You have been asked to pay the total copayment amount of $1,185 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care 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 from March 7, 2020 to March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC). 
 
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 a Group 3 PWC is covered when specific criteria 
are met. 
 
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 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have a mobility limitation, but there is conflicting documentation and only refers to a history of stroke. 
Furthermore, there is no physical exam findings in the documentation with details of neuromuscular findings 
consistent with paralysis to one side of the body (hemiplegia). The progress note dated August 12, 2020 states a 
review of systems was negative for neurological issues and positive for difficulty walking. There is no clear, 
consistent evidence of a neurological condition impairing mobility-related activities of daily living (MRADLs) 
in the home. The Group 3 PWC is therefore 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 a Group 3 power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for acute inpatient hospital care. 
 
You asked the Plan to pre-approve for acute inpatient hospital care. You say that this is medically necessary. 
The Plan denied your request. The Plan says the enrollee could be treated in observation. 
 
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 pre-approve for 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 based on the presentation, the diagnosis was likely uncomplicated urinary 
tract infection. The enrollee's vitals were stable, and there was no other finding which would have warranted 
inpatient treatment for her condition. At the time of admission, there was insufficient evidence to support that 
the patient would require at least 2 midnight's of hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve for acute inpatient hospital care.