Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one further home health occupational therapy (OT) 
visit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says eight visits are approved and one further is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition.  
 
She has had prior therapy and the records do not indicate that her functional level requires the ongoing unique 
skills of a professional therapist to safely and effectively provide treatment. She was trained in an exercise 
program. The services are not part of a maintenance program and are not needed to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 pre-approve one further home health occupational therapy (OT) visit.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee March 18, 2020. 
 
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 this claim should be submitted to Original Medicare due to the hospice election. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee March 18, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation for her common, non-surgical, weight-bearing fracture. The enrollee's care needs can be 
met at a lower level of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional skilled nursing in home visits and 9 home 
health aide visits. 
 
You asked the Plan to pre-approve the 2 additional skilled nursing in home visits and 9 home health aide visits. 
The Plan denied your request. The Plan says the additional services do not meet coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
 
 
The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled 
nursing or therapy. 
 
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 2 additional skilled nursing in home 
visits and 9 home health aide visits. Our reviewer says that additional skilled nursing home visits and home 
health aide visits are not reasonable and necessary. Our physician reviewer found home health aide visits note 
to encourage fluids and light housekeeping. The skilled nursing visits indicate no evidence of wound care, pain 
management, or medication changes. The enrollee had start of care of home services July 16, 2020 and as of  
August 29, 2020 had at least 19 visits. The enrollee noted to ambulate with CPC and is independent at home 
and up as tolerated. She has no pain. She needs occasional assist. She denies shortness of breath per the August 
24, 2020 skilled nursing visit. The records do not show that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee does not 
have complex wounds or other skilled nursing. She has had prior skilled nursing and should be educated on her 
condition. The documentation does not clearly reveal that leaving the home is a taxing effort and therefore, the 
services do not meet the definition of home health aide services as per Section 50.2. The requested home health 
aide services are not reasonable and necessary to the treatment of the patient's illness or injury by the skilled 
professional staff. 
 
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 2 additional skilled nursing in home visits and 9 home health aide visits. 
have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional skilled 
nursing in home visits and 9 home health aide visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the cervical spine (72125). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says the clinical information provided 
does not indicate a reason to approve the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT Scan. Our reviewer says that the 
provided records do not support the CT scan. There was no reported cervical or related symptoms, no physical 
findings suggestive of a cervical lesion, and no explanation or justification made in the documentation as to the 
reason for this test. Our physician reviewer found this request for CT cervical spine will be considered not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan of the cervical spine (72125).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the enrollee is currently medically stable after a syncopal episode and fall. There 
is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three 
times per week or acute rehabilitation nursing care. While she may benefit from continuing physical and 
occupational therapy, there is no evidence of a need for an intensive therapy program with therapy three hours 
per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The 
enrollee's rehabilitation needs can be met in a lower intensity alternate setting such as in a skilled nursing 
facility. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 13, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the chest x-ray (71046). You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says medically necessary services were available 
within the network and there are no extenuating circumstances making it medically necessary to have obtained 
this service out-of-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 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 May 13, 2019 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on 
April 10, 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 enrollee did not have prior authorization for out of network care. 
 
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 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 physician services provided to the enrollee out of network on 
April 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional panoramic x-ray and three additional 
extractions provided from August 20, 2019 through January 14, 2020.  
 
You asked the Plan to pay for the additional panoramic x-ray and three additional extractions. You say that 
your coverage says you can go to any dentist. You say that you paid out of pocket and need to be reimbursed. 
The Plan denied your request. The Plan says out-of-network dental services are 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, you also have a maximum benefit of 
one panoramic x-ray every five years and two extractions every year. The Plan paid for one panoramic x-ray 
provided on September 4, 2019, one extraction provided on September 4, 2019 and one extraction provided on 
September 19, 2019, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay 
for the additional panoramic x-ray and three additional extractions provided from August 20, 2019 through 
January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral injections (64483). 
 
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says the records do not show that this 
treatment plan will not exceed appropriate limits. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the member did not have significant pain relief from the prior epidural steroid injections and no 
recent physical therapy. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral injections (64483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewing x-rays and prophylaxis 
provided on February 6, 2020. 
 
You asked the Plan to pay for a periodic oral evaluation, bitewing x-rays and prophylaxis. You say that the 
information provided states a $0 copayment for in-network and out-of-network. The Plan denied your request. 
The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for your covered benefits. You are responsible for the difference between the billed amount 
and amount paid by the Plan. Therefore, we decided that the Plan does not have to pay for a periodic oral 
evaluation, bitewing x-rays and prophylaxis provided on February 6, 2020.  
 
Your complaint about the interpretation being misleading is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the needle electromyography (EMG) testing provided on January 24, 
2020. 
 
You asked the Plan to pay for the EMG testing. You say that this service is payable and was medically 
necessary. The Plan denied your request. The Plan says that EMG cannot be used alone to diagnose 
radiculopathy or peripheral nerve disorders. This must be provided with nerve conduction studies to make this 
diagnosis as per the relevant Local Coverage Determinations (LCDs). 
 
Please note that review of the cited LCDs indicates that they are limited to coverage rules only for the specific 
listed indications. As this EMG testing was not being done to diagnose radiculopathy or peripheral nerve 
disorders, and the LCD did not provide guidance on EMG for intraoperative monitoring, we find that these 
coverage rules do not apply to this case.  
 
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 pay for the EMG testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the patient had lumbar surgery with a lateral approach. There is risk to damage the nerves coming out of 
the spine. EMG is needed to detect this. The use of EMG in this case should be approved with the 
interpretation services also as they are needed to detect the nerve damage. It is the standard of 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 the EMG testing have been met. Therefore, we decided that the Plan has to pay 
for the needle electromyography (EMG) testing provided on January 24, 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 admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records show that it is not reasonable to expect that the enrollee would be able to 
fully benefit from the intensity of services available 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 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 do 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. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is 
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an 
IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that you are currently medically stable after a hip fracture. There is no evidence of 
complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or 
acute rehabilitation nursing care. While you may benefit from continuing physical and occupational therapy, 
there is no evidence of a need for an intensive therapy program with therapy three hours per day with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. Your rehabilitation needs can be 
met in a lower intensity alternate setting such as at home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on December 23, 2019. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says there is insufficient medical record documentation of a valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate medical record documentation. In this case insufficient 
physician records were provided to support this claim. Medicare coverage criteria for payment of this claim are 
not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on 
December 23, 2019.