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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care. 
 
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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following 
surgery for a newly diagnosed gastric cancer. The enrollee was transiently intubated/ventilated, but is no longer 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating facility on December 11, 2019. 
 
You asked the Plan to waive the copayment for an injection. You say that you cannot afford this copayment. 
You say that you were not informed prior to these services that you would owe this much. The Plan denied 
your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $325 copayment for an injection. The correct copayment has been applied to the 
services that were provided. An injection falls within the outpatient surgery 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 outpatient surgery provided by a participating facility on 
December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift battery. 
 
You asked the Plan to pre-approve a stair lift battery. You say that you need a new battery in order to go up or 
down the staris. The Plan denied your request. The Plan says that this is not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item and 
therefore, a battery for a stair lift cannot be covered. Therefore, we decided that the Plan does not have to pre-
approve a stair lift battery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on February 26, 2020 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that the issue you went to the dentist for was not addressed. You also say that you are wheelchair 
bound, and the provider did not have the facility to do a complete x-ray. The Plan denied your request. The 
Plan says the 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 problem 
focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on February 26, 
2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that proton therapy for prostate cancer has 
demonstrated extremely high efficacy in biochemical control. The Plan denied your request. The Plan says the 
requested service is not the standard of care for prostate cancer. 
 
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 requested services. Our physician 
reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. The generally accepted standard of care for prostate 
cancer is to only offer proton beam therapy on clinical trials, and not routinely offered. Therefore the requested 
service is not considered medically reasonable or necessary 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 21, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on January 21, 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 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 enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of 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 was admitted for weakness and falls. 
Medical problems are stable. 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. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for services provided on January 8, 2020. 
 
You asked the Plan to waive the copayment for the facet joint injection. You say that you should not have a 
copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment from services obtained from a specialist for Physician/Practitioner Services.  
 
You have been asked to pay a $5 copayment from services obtained from a specialist for the facet joint 
injection. the facet joint injection falls within the Physician/Practitioner 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 services provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 5, 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 for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that these services were provided out-of-area. 
 
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 
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 February 5, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99239) provided on November 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in 
question. 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 99239) provided on 
November 24, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. The Plan denied your request. The Plan says 
that the enrollee had a negative cardiac workup, and no acute events during her observation stay. 
 
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 acute inpatient hospital care. Our 
physician reviewer found that the enrollee presented to the emergency room with chest pain. The evaluation 
revealed BP 195/83 and the physical exam was unremarkable. Labs including cardiac biomarkers were normal; 
EKG was without any acute ischemic changes. She was admitted and evaluated by Cardiology.Lexiscan study 
was negative for ischemia. The review has determined that the record showed that the physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says the enrollee 
has not tried and failed Orthovisc and Monovisc. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 requested drug. Our physician 
reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of 
Orthovisc and Monovisc before they will approve the requested drug. The file does not contain documentation 
of a trial and failure of Orthovisc and Monovisc. The documentation does not support that Orthovisc and 
Monovisc would likely be less effective, or would likely have adverse effects for the enrollee. 
 
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 requested drug have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Synvisc-One.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on June 24, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you weren't even seen 
when you went to the ER. You say that you sat there and then decided to leave when you were told it would 
take 4 more hours to be seen. The Plan denied your request. The Plan says the correct copayment has been 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay $76.62, which is less than your copayment amount of $90 for an emergency room 
visit. Since an emergency room visit was provided, the correct copayment has been applied. An emergency 
room visit falls within the emergency 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 emergency room visit provided by a participating provider on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, bone replacement graft for ridge preservation, 
and first 15 minutes of deep sedation/general anesthesia provided on January 20, 2020. 
 
You asked the Plan to pay for the extraction, bone replacement graft, and deep sedation/general anesthesia. 
You say that you were told you would have $1,000 in dental coverage, and you would be able to get your 
money back. You also say that you were never told that the provider had to be in-network, or that the dental 
office had to sign different forms. The Plan denied your request. The Plan says these services were rendered by 
a provider who opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the extraction, bone replacement graft for ridge preservation, and first 15 minutes of deep sedation/general 
anesthesia provided on January 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the orbit and ear. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee complains of neck pain, and the request is for the orbit and ear. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no symptoms 
for which the requested CT (CPT 70480) is appropriate. MRI of the cervical spine is the procedure of choice 
with which to evaluated cervical spine. For this enrollee, the results of plain films are not included in the 
submitted records. The neurological exam is unremarkable and there is no prior history of trauma or tumor. 
There has been no six week trial of physical therapy. There is a request on file for MRI of the lumbar spine 
dated 9/28/20 aand there is no documented contraindication to MRI such as pacemaker etc.  In summary, the 
medical necessity for the requested CT (CPT70480) has not been established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the orbit and ear.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty manual wheelchair with footrest. 
 
You asked the Plan to pre-approve wheelchair. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for this item is correct, because the documentation does 
not indicate that there is adequate access in the enrollee's home to support the use of this wheelchair or why the 
enrollee's ability to participate in mobility-related activities of daily living (MRADLs) cannot be met with a 
walker or other device.  
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is only covered if certain 
specific clinical 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 wheelchair. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested wheelchair. Our physician reviewer found the 
documentation does not indicate that the enrollee has a mobility limitation that significantly impairs her ability 
to participate in 1 or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, 
dressing, grooming, and bathing in customary locations in the home. The documentation does not specifically 
discuss which activities of daily living are affected by any mobility limitation or whether she is unable to 
accomplish them safely and effectively. The enrollee has no upper or lower extremity weakness; therefore, it is 
not clear why her mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane 
or walker. There is no evaluation of the home indicating adequate access between rooms, maneuvering space, 
and surfaces for use of the manual wheelchair requested. It is not clear that the use of a manual wheelchair will 
significantly improve the enrollee's ability to participate in MRADLs and that the enrollee will use it on a 
regular basis in the home. There is no documentation of the enrollee's weight on the medical progress reports to 
indicate whether she requires a bariatric wheelchair. Therefore, the requested wheelchair and accompanying 
footrest are 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty manual wheelchair with footrest.