Persius/hicric huggingface dataset:
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 you were independent before hospitalization. The 
Plan denied your request. The Plan says it is not reasonable to expect you will be able to fully participate in the 
intensity of services in an IRF. 
 
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 you were admitted to the acute hospital for coronary artery bypass grafting. Your medical problems are 
stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 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. The medical record supports a 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total hip arthroplasty (THA) surgery. 
 
You asked the Plan to pre-approve THA surgery. You say that the enrollee has osteoarthritis and needs this 
surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the submitted records do not show recent examination findings or that the enrollee has severe enough 
symptoms to need this surgery.  
 
The Plan follows Medicare rules. Medicare rules say that total hip arthroplasty is only covered when the 
clinical criteria listed on the previous page have been 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 THA surgery. Our reviewer says that 
the enrollee does not meet the Medicare criteria for this surgery. Our physician reviewer found there is no 
documentation of the degree of disability and degree of pain. More information is needed to justify the surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of THA surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total hip arthroplasty (THA) surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 31, 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 codes 82947 and 80061 are 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 82947 is glucose; quantitative, blood (except reagent 
strip). The definition of code 80061 is lipid panel. 
 
We find that CPT codes 82947 and 80061 are not supported in the medical record. Specifically, there are no 
submitted documented lab results. 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 laboratory 
services rendered on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on June 9, 2020, to June 25, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you believed that the services had received 
prior authorization and you were only liable for a copayment. The Plan denied your request. The Plan says the 
prior authorization referral expired on June 2, 2020. Accordingly, prior authorization for the dates after June 2, 
2020, 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 physician services provided on June 9, 2020, 
to June 25, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the otolaryngology visit you had on August 
31, 2020. 
 
You asked the Plan to waive the copayment for the otolaryngology visit. You say that you should not have to 
pay this copayment because all they did was weigh you and take your temperature. 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 $40 
copayment for visits to a specialist.  
 
You have been asked to pay a $40 copayment for the otolaryngology visit. This copayment applies regardless 
of the extent of services you receive during the visit. 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 
the otolaryngology visit you had on August 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Neulasta injection (J2505). 
 
You asked the Plan to pre-approve Neulasta. You say that Neulasta is medically necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says you do not meet medically accepted standards for 
coverage of this drug. 
 
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 Neulasta. Our reviewer says that the 
Neulasta is not medically necessary. Our physician reviewer found this review relates to a request for Neulasta 
to treat a 65-year-old woman receiving Carboplatin and Paclitaxel for primary peritoneal cancer.  The 
submitted documentation does not indicate she has had an episode of neutropenic fever during this same 
chemotherapy. The use of the drug is for patients with previous neutropenic fever or with clinically significant 
incidence of febrile neutropenia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Neulasta injection (J2505).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a life vest (K0606) paid for on April 16, 
2020. 
 
You asked the Plan to waive the coinsurance for a life vest. You say that you were not aware of the 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance was 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay $585.12, or 20% of the Plan-allowed amount of $2,925.60, for a life vest. A life 
vest falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a life vest (K0606) paid for on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 7, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 21, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 a domiciliary, rest home visit provided on June 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided from February 17, 2020, 
through March 17, 2020. 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
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 outpatient services provided from February 17, 2020, through 
March 17, 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 enrollee's physician feels that the enrollee needs 
rehabilitation at the acute level. 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 
was admitted for elective lumbar decompression surgery and medical problems are stable. While the enrollee 
may require treatment by multiple therapies, including either physical therapy or occupational therapy, the 
medical record does not support a need for an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 21, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care from April 25, 2019, through April 27, 
2019. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for inpatient hospital care was not filed to the member's primary insurance 
within the one calendar year from the date of service. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care from April 25, 2019, through April 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the veneer (D2962) provided on July 8, 2020. 
 
You asked the Plan to pay for the dental item. You say that your veneer was cracked and needed to be replaced. 
You say that your front tooth veneers are not cosmetic because you need them to eat. You also say that 
replacement was very important for your physical health. The Plan denied your request. The Plan says veneers 
are specifically excluded from coverage. 
 
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 veneer 
(D2962) provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forspecialist office visit provided on June 24, 2020.You asked the Plan to waive the copayment forspecialist office visit. You say that you do not believe you should have to pay a copay.The Plan denied your request. The Plan says the cost share is correct.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 $50 copayment for specialist visit forPhysician/Practitioner services, including doctor's office visits. You have been asked to pay a $50 copayment for specialist visit for specialist office visit. This service falls within the Physician/Practitioner services, including doctor's office visits 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 forspecialist office visit provided on June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you provided medically necessary services in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 laboratory services provided on September 30, 
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need the LTACH services. The Plan 
denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that there is no documentation provided necessitating admission to a LTACH. You 
still require acute hospital level of care services and are receiving appropriate care at the present acute care 
hospital. The review has determined that you do not require services at the LTACH that are not available at the 
acute care hospital where you are currently receiving care. There are no services available at the LTACH that 
you require that are not available at the health care setting being offered by the Plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for your diagnosis and condition nor are able 
to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 19, 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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on June 9, 
2020. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you were not charged for 
your previous urgent care visit. The Plan denied your request. The Plan says the copayment applied 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 $10 
copayment for each visit. Covered services include urgently needed services obtained at a retail walk-in clinic 
or an urgent care center.  
 
You have been asked to pay a $10 copayment for the urgent care visit. The urgent care visit falls within the 
"Urgently Needed 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 the urgent 
care visit provided on June 9, 2020.