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

 
We decided that the Plan does not have to pay for the emergency department (ED) services rendered on 
October 26, 2019. 
 
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 99285 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 99285 is Level 5 emergency department visit for 
evaluation and management of patient with problem immediately threatening life, including comprehensive 
history and physical examination, and medical decision-making of high complexity. 
 
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 these services. Our reviewer says that 
procedure code 99285 is not supported. Our physician reviewer found billing CPT 99285 requires the 
documentation of a comprehensive history, comprehensive examination and medical decision making of high 
complexity.  Furthermore, the complaint is usually one of great severity, which poses an immediate risk to the 
health of the patient.  In this case, the enrollee was seen in the ED for not getting along with his mother.  The 
enrollee was well behaved in the ED and was not deemed to be a threat to himself or others.  Basic laboratory 
testing was performed and the enrollee was discharged to follow up with his PCP.  As such, the billing of CPT 
99285 is not supported. 
 
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 pay for the emergency department (ED) services rendered on October 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported metal crown (D6067) and the 
surgical placement of a mini implant (D6013). 
 
You asked the Plan to pre-approve the dental services. You say that you need the implants because you are 
having trouble eating. You also say that you have poor self-esteem. The Plan denied your request. The Plan 
says implant supported metal crown is not listed and therefore is not a covered service. The Plan says surgical 
implant of a mini implant is not listed as a covered service either. The Plan also says any services not listed are 
not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported metal crown (D6067) and the surgical placement of a mini implant (D6013).
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 rehabilitation would help you gain your 
independency. The Plan denied your request. The Plan says the IRF 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do 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. Our 
physician reviewer also found that 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 acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns for tooth #'s 4, 12, 20 and 28. 
 
You asked the Plan to pre-approve the crowns for tooth #'s 4, 12, 20 and 28. The Plan denied your request. The 
Plan says the teeth do not appear to have significant breakdown. 
 
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. The Plan covers the crowns 
for tooth #'s 4, 12, 20 and 28 when the services are medically necessary and reasonable.  
 
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 crowns for tooth #'s 4, 12, 20 and 
28. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer found that there is 
no clear indication for crowns on any of the teeth as there is minimal to no damage. Our reviewer says that 
given the provided records, the request for crowns is not supported and does not meet policy criteria or medical 
necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns for tooth #'s 4, 12, 20 and 28 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the crowns for tooth #'s 4, 12, 20 and 28.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the immunohistochemistry services rendered on April 6, 2020. 
 
You asked the Plan to pay for these services. You say that you only billed three units. The Plan denied your 
request. The Plan says that the procedure was originally billed with multiple units. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the procedure was originally billed with multiple units. The 
claim shows that the provider billed three units of this code. The MUE value for this code is six; therefore, the 
provider did not exceed the MUE for this code. The Plan did not provide any documentation to support that 
three units of the code are not payable as billed. Therefore, we decided that the Plan has to pay for the 
immunohistochemistry services rendered on April 6, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from a short stay or IRF 
to improve her functional independence, with transition to home health afterwards. The Plan denied your 
request. The Plan says the denial of authorization for IRF service is correct. 
 
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 does 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. While the 
enrollee may benefit from multiple therapies such as physical and occupational therapy, 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 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 polycarbonate lenses. 
 
You asked the Plan to pre-approve these services. You say that it is not safe to have lenses without the 
polycarbonate coating. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the use of polycarbonate is denied as noncovered. 
 
We looked at the file and Medicare rules. The services at issue are polycarbonate lenses. These services are 
denied by Medicare as a noncovered deluxe feature. Therefore, we decided that the Plan does not have to pre-
approve polycarbonate lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network podiatrist. 
 
You asked the Plan to pre-approve these services. You say that the providers that can manage your diagnosis 
within the network have been exhausted. The Plan denied your request. The Plan says the services are available 
from network providers. 
 
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. The Plan has in-network tertiary level 
providers that can provide the same level of care as the requested provider. 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 a referral to an out-of-network podiatrist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the continuation of medically necessary 
acute care services of a LTACH is medically appropriate for the enrollee. The Plan denied your request. The 
Plan says transfer to a LTACH is not medically necessary at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already being 
provided at the current setting. Our reviewer found that there are no services at the LTACH that the enrollee 
requires that are not available and covered at the current setting. Our physician reviewer also found that 
continuing care at the current hospital appears appropriate at the time. Transfer to a lower level of care may be 
considered soon. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation with an out of network 
neurosurgeon at a tertiary level of care. 
 
You asked the Plan to pre-approve the out of network consultation at a tertiary level of care. You say that you 
trust the opinion of the out of network, tertiary level of care provider. The Plan denied your request. The Plan 
says the enrollee can get medically needed care from a non-tertiary level provider within the network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollee's 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 the out of network consultation at a 
tertiary level of care. Our reviewer says that the criteria for out of network care have not been met. Our 
physician reviewer found the enrollee's plan has an adequate network of providers available who are able to 
consult on the enrollee's condition. The enrollee has recently been diagnosed with a glioblastoma (GBM). His 
tumor (based on its location) is not readily amenable to resection. In such a case the standard of care would be 
to refer a patient to oncology (and radiation-oncology) for further consultation and treatment (in accordance 
with NCCN guidelines). The plan has demonstrated that they have such providers available. The plan also has 
other in-network neurosurgeons available who can provide second (or third) opinions as necessary. There is 
nothing unique about the enrollee's condition that would make it medically necessary to see the requested out 
of network provider at a tertiary level of care. The request to see the out of network provider appear to be one 
of patient preference. The Plan has demonstrated an adequate network, including the availability of two tertiary 
centers if necessary. However, at this time, the enrollee can obtain a non-tertiary second opinion on his tumor. 
The primary question would be if it is amenable to resection or debulking at this time. A tertiary intervention at 
this time would not be expected to change the outcomes or further care of said 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 out of network consultation at a tertiary level of care have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a second opinion consultation with an out of 
network neurosurgeon at a tertiary level of care.
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 this enrollee meets the full criteria for an inpatient 
acute rehab stay. The Plan denied your request. The Plan says the request for IRF services 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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 acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Upper 
Extremity (73222). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the requested MRI scan is medically reasonable and necessary at this point. Given the 
negative x-ray findings, negative physical examination findings and negative history of trauma, six to twelve 
weeks of conservative treatment with physical therapy, anti-inflammatories and splinting is indicated prior to 
performing the MRI scan. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the Upper Extremity (73222).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that states the enrollee's urologist 
suggested removal of the uterus due to fibroids and you would like a professional opinion from the requested 
physician. The Plan denied your request. The Plan says the information from the enrollee's provider does not 
indicate that the enrollee requires specialized services that cannot be provided in the enrollee's preferred 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services (D2950). 
 
You asked the Plan to pre-approve core buildup services. The Plan denied your request. The Plan says this is 
not a covered benefit. 
 
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 services are not among 
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. 
Core buildup services are not covered. Therefore, we decided that the Plan does not have to pre-approve core 
buildup services (D2950).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that , if the enrollee were to have to go home he 
would have increased danger of falling and returning back to the hospital. You say that the enrollee needs 
further skilled nursing and rehab care. The Plan denied your request. The Plan says the services the enrollee 
requires can safely be received in the current inpatient facility setting. 
 
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, had stable vital signs, and clear lungs. The enrollee received physical therapy, speech therapy, and 
occupational therapy in the acute hospital. The enrollee was at a contact guard to minimal assist level with 
functional mobility, including gait to 180 feet with a rolling walker. The enrollee required varying assist with 
 
 
activities of daily living. The enrollee tolerated a dysphagia soft diet. There are no identifiable skilled nursing 
service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. 
The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 skilled nursing facility (SNF) services.