Persius/hicric huggingface dataset:
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 the enrollee should continue physical 
therapy and occupational therapy for rehab treatment. You say that the enrollee's family is concerned with 
safety to manage medications and because the enrollee is at high risk for fall and readmission. You say that the 
enrollee lives alone and has no one who can help. The Plan denied your request. The Plan says the enrollee's 
condition does not meet the requirements for coverage of SNF care. The Plan says that the enrollee is now 
stable and does not require complex daily skilled rehabilitation therapy or complex daily nursing care. 
 
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 with bradycardia, and was continued on her psychotropic medications.  
 
 
The enrollee received physical 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 200 feet with a rolling walker. 
The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs, but 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 SNF 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Outpatient Surgery CardioMEMS device. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the records show that the member may have a problem that involves the pressures in the 
vessel that carries blood from their heart to their lungs. The Plan states there is not enough research showing 
that the type of device you are requesting would be helpful for the member. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this circumstance, therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy). Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart 
failure. Medicare coverage criteria are not met, since the device should still be considered experimental or 
investigational. 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 Outpatient Surgery CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 1, 2020 by an 
out of network (OON) provider. 
 
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 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 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 medical services provided on September 1, 
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (R0070) provided. 
 
You asked the Plan to pay for portable x-ray services. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
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 CPT code R0070 is not supported in the medical record. Specifically, medical records have not 
been submitted to support this service. Based on this information, we decided that Medicare rules for coverage 
of portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for 
portable x-ray services (R0070) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction of genicular nerve branches of knee by 
injection using imaging guidance (64624). 
 
You asked the Plan to pre-approve the destruction of genicular nerve branches of knee by injection using 
imaging guidance. You say that the services are medically necessary. The Plan denied your request. The Plan 
says the services requested are considered experimental or investigational. 
 
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 destruction of genicular nerve 
branches of knee by injection using imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found this is an 
experimental investigational procedure that is the subject of ongoing clinical trials and the member is not 
enrolled in any clinical trials. 
 
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 destruction of genicular nerve branches of knee by injection using imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve the destruction 
of genicular nerve branches of knee by injection using imaging guidance (64624).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee was referred to a spine specialist for 
ongoing treatment and evaluation. You say that you have submitted new clinicals to demonstrate why the MRI 
is needed, but the Plan is not reviewing these records due to the previous denial. The Plan denied your request. 
The Plan says that that medical necessity has not been established for the requested MRI. 
 
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 
criteria for coverage have been met. Our physician reviewer found the enrollee had prior review where the 
exam showed no decreased strength and no radicular nature. A subsequent exam and history noted radicular 
nature of pain. The enrollee has radicular pain and an MRI is indicated. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the lumbar spine.  
 
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 waive the copayment for the inpatient stay provided from March 11, 
2020, through March 24, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that the testing for Covid during 
your stay should be enough to have this covered under the Covid resolution. You say that the claim should be 
paid. 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 $295 
copayment per day, days 1 to 6 and a $0 copayment per day, days 7 to 90 at an in-network inpatient hospital. 
 
You have been asked to pay a $1,770 copayment for the inpatient stay. ($295/day x first 6 days = $1,770). The 
inpatient stay falls within the "Inpatient hospital care" benefit category. The Plan says that only out-of-pocket 
costs for in-network primary care, behavioral health, and virtual visit services from May 1, 2020 through 
December 31, 2020 are being waived.  
  
 
 
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 inpatient stay provided from March 11, 2020, through 
March 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care from December 14, 2020, forward. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 altered mental status and fever and was treated for a urinary tract infection. Medical conditions are 
stable. There are no medical needs requiring inpatient admission. 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. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation 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. 
 
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 IRF care from December 14, 2020, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on July 14, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99212. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
provider submitted a claim for procedure code 99212 (office visit). Therefore, we decided that the Plan does 
not have to pay for the office visit rendered on July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization care from August 5, 2018, through August 
7, 2018. 
 
You asked the Plan to pay for post-stabilization care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the patient was stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
 
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 post-stabilization care. Our reviewer says 
that the service was not medically necessary. Our physician reviewer found the records do not show the patient 
not being stable for transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for post-stabilization care from August 5, 2018, through August 7, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you had another CT scan two weeks 
prior to this one and you weren't charged a copayment. The Plan denied your request. The Plan says you were 
appropriately charged a copayment for both CT scans. 
 
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 $150 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the Medicare-covered 
radiological diagnostic 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 computed tomography (CT) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, spine, lumbosacral (72110). 
 
You asked the Plan to pay for the radiologic examination. You say that your no fault carrier has refused to pay 
for any medical needs going forward from your accident on 7/05/2017. The Plan denied your request. The Plan 
says this claim has not been submitted to the no-fault carrier. The no-fault claim is still open. The claim must 
be submitted to the primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the plan is 
secondary to the enrollee's no-fault insurance provided May 11, 2020. As the secondary insurer, the Plan 
cannot be held responsible for the radiologic examination until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for radiologic examination, spine, 
lumbosacral (72110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 syncope due to a massive pulmonary embolus. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation 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. 
 
 
 
 
 
 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 23, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim was not received until August 28, 2020. 
 
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 this service was not filed until August 28, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for physician services provided to the enrollee on May 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided from January 8, 2020, to 
August 8, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you are not supposed to be charged for the 
device. 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 20% 
coinsurance for DME and related supplies.  
 
You received DME from January 8, 2020, to August 8, 2020, for a total of 8. The allowed amount per each 
date of service is $81.01 and 20% of that is $16.20. The total amount you owe is: $16.20 (coinsurance) x 8 
(dates of service) = $129.60.  
 
You have been asked to pay the total coinsurance amount of $129.60 for DME. DME falls within the 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 DME provided from 
January 8, 2020, to August 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PET scan provided. 
 
You asked the Plan to pay for the PET scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The PET scan at issue in this appeal was requested solely for screening purposes. The diagnosis code billed 
with this procedure code specifically supports that this service was billed for screening services (C34.90 - 
Malignant neoplasm of unspecified part of unspecified bronchus or lung). Medicare does not cover this test 
solely for screening purposes. Diagnosis code C34.90 is not listed as an appropriate diagnosis in the CMS 
Change Request 8739 (Transmittal 3162). Therefore, we decided that the Plan does not have to pay for the PET 
scan provided.