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

 
We decided that the Plan has to pay for acute inpatient hospital admission for the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the documentation does not support the need for an acute inpatient 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would 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 pay for acute inpatient hospital admission for the enrollee.  
 
 
 
 
 
 
 
 
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 long-term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
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. The enrollee 
still requires hospital level of care services and is receiving appropriate care at the present acute care hospital. 
The enrollee does not require services at the LTACH that are not available at the acute care hospital where she 
is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 for the enrollee.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness, knee pain and falls. 
Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no 
complex nursing or rehabilitation needs. You do 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 you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that your 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided 
from February 1, 2019, to February 7, 2019. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you should not 
owe a copayment for the inpatient rehabilitation stay. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for days 1-6 for inpatient hospital care.  
 
You have been asked to pay $1,475, which is less than the total copayment amount for an inpatient 
rehabilitation stay. An inpatient rehabilitation stay falls within the inpatient hospital care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided from February 1, 
2019, to February 7, 2019.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Revlimid (J8999) and Darzalex Faspro. 
 
You asked the Plan to pre-approve Revlimid and Darzalex Faspro. You say that these services are medically 
necessary to treat the enrollee's cancer. The Plan denied your request. The Plan says that this treatment is not 
recommended by the National Comprehensive Cancer Network and there may be better choices for treating the 
enrollee's cancer. 
 
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 Revlimid and Darzalex Faspro. Our 
reviewer says that the services are medically reasonable and necessary for the enrollee's condition. Our 
physician reviewer found there is clinical research that appears in a CMS-approved medical journal that 
supports the use of these drugs to treat the enrollee's relapsed/refractory cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Revlimid and Darzalex Faspro have been met. Therefore, we decided that the 
Plan has to pre-approve Revlimid (J8999) and Darzalex Faspro.  
 
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 admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services can be safely received in another setting, such as an inpatient 
rehab facility, skilled nursing facility, or home with home health services. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file 
does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. 
Consequently, the requested LTACH services are/are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on September 11, 2020. 
 
You asked the Plan to pay for surgical services. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
Plan is the secondary payer for this enrollee and cannot process the claim until the primary payer has. 
 
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 instructed 
you to submit this claim to the enrollee's primary payer for processing. As the secondary insurer, the Plan 
cannot be held responsible for surgical services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for surgical services provided on September 
11, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve maxillary sinus dilation. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the medical record does not document at least four episodes of sinusitis in the last 
six months. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found you suffer from chronic sinusitis with acute flare-ups. You have been on medical management but 
continues to have recurrent sinus infections. The CT shows evidence of chronic sinusitis as well as structural 
obstruction of her sinus outflow tracts. Therefore, you would benefit from a sinus procedure to open the 
drainage pathways. This could be performed by doing endoscopic sinus surgery or balloon dilation. Balloon 
dilation of the sinuses is FDA approved, not considered experimental, and is endorsed by the Academy of 
Otolaryngology. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve maxillary sinus dilation.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or outpatient visit (99215) rendered by the out of 
network. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office or outpatient visit (99215) rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for anesthesia for diagnostic or therapeutic 
nerve blocks and injections (01992) provided September 9, 2020. 
 
You asked the Plan to waive the copayment for the anesthesia services. You say that choosing to have an 
invasive pain procedure can cause anxiety and hypertension. Chronic pain patients are already at risk for 
anxiety due to the pain they experience every day. The Plan denied your request. The Plan says this service was 
not medically necessary. 
 
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 waive the copayment for the anesthesia 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 case, the clinical records provided did not support the P3 (ASA 
3) indicator for this enrollee. There was no documentation as to enrollee's condition that warranted neither the 
P3 modifier nor the overall medical necessity for the need of monitored anesthesia care. Per the LCD, facet 
joint interventions for pain management (L34892), neither conscious sedation nor monitored anesthesia care 
(MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks. The review has 
determined that the items/services at issue in this case were not medically reasonable and 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 the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to waive the copayment for anesthesia for diagnostic or therapeutic nerve blocks and injections 
(01992) provided September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0274), and 
prophylaxis (D1110) provided on August 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that the Evidence of Coverage says the services you 
received are covered two times per year. You also say that by denying payment for services that are part of 
your plan, the plan is breaking their contract with you. The Plan denied your request. The Plan says the Dental 
Rider cannot be combined with the Supplemental Dental Benefit. The Plan says that there is an annual 
maximum of $1,000 for covered dental services. The Plan also says that the annual maximum has been 
exhausted. 
 
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 and the services you received are listed 
as covered, the annual maximum of $1,000 has been exhausted. The record shows that the Plan paid $1,000 for 
services that you received on February 11, 2020, thus exhausting the benefit. Additionally, the Evidence of 
Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-
rays (D0274), and prophylaxis (D1110) provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
tertiary level provider. 
 
You asked the Plan to pre-approve the continuation of care with an OON tertiary level provider. You say that 
you want to remain under the care of the requested OON provider. You say that this doctor has been 
supervising your breast cancer treatment course since 2018. You say that you do not want to see a new doctor 
and that this OON provider has gone to great lengths to determine the best course of treatment for your breast 
cancer. The Plan denied your request. The Plan says the enrollee's current care needs are not acute and can be 
safely transitioned to an in-network oncologist/hematologist. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continuation of care with an OON 
tertiary level provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our 
physician reviewer found you are not currently receiving any active treatment and/or medical management of 
your condition which makes it medically necessary to continue care with the OON provider requested. Our 
physician reviewer found that you are on oral treatment that can easily be transitioned. There is nothing unique 
about your condition that would make it medically necessary to continue care OON. Your treatment has been 
according to the standard of care. You are not on a clinical trial. The need to try different oral therapies for 
endocrine therapy is common. The Plan has shown that they have in-network specialists who have the 
qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of 
your condition. Your medical management and/or follow-up care can be safely transitioned to an in-network 
specialist. It is not medically necessary that you care be provided at a tertiary level provider. 
 
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 continuation of care with an OON tertiary level provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network 
(OON) tertiary level provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 very heavy duty power operated vehicle 
(POV). 
 
You asked the Plan to pre-approve a Group 2 very heavy duty POV. You say that you meet the weight 
requirement for this wheelchair. The Plan denied your request. The Plan says that this is not covered for the 
member's condition. 
 
The Plan must follow Medicare rules. The rules say that Group 2 POVs are denied as not reasonable and 
necessary.  
 
The item at issue is a Group 2 POV. This item is denied by Medicare for all indications. This means that 
Medicare rules for coverage of the POV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Group 2 very heavy duty power operated vehicle (POV).