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 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 surgical repair of a hip fracture after a fall. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a UroLift procedure. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have benign prostatic hyperplasia (BPH) with lower urinary tract symptoms and urinary retention. You have an 
obstructive intravesical median lobe present. The use of UroLift in this instance is not recommended. The 
services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a UroLift procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to move on with your care. You say that 
you have been in the hospital 9 days and you are not able to take care of yourself and no one resides with you 
currently at home. The Plan denied your request. The Plan says that based on Medicare guidelines and the 
information the Plan has about your condition, the requirements for an IRF admission have 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
treatment of upper and lower extremity deep vein thrombosis. 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 
 
 
 
 
 
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 admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee from June 3, 
2018, to June 6, 2018.  
 
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 it was verified the enrollee had a primary payor effective from November 2, 1017 to 
April 30, 2019. The Plan states an explanation of benefits showing the primary has addressed this claim is 
required before the Plan will review as the secondary payor.  
 
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. The Plan has met its obligation with 
regards to coordination of benefits. The Plan has identified the primary payor at the time of service and 
instructed claim submission. Therefore, we decided that the Plan does not have to pay for outpatient services 
provided to the enrollee from June 3, 2018, to June 6, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford the charges. 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 $0 
copayment for each diagnostic mammograms and a $110 copayment for radiological diagnostic services.  
 
You have been asked to pay a $0 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests and therapeutic services and 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 copayment 
for a CT scan provided.
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. The Plan denied your request. The Plan says you do not need a 
rehab physician visit three times a week, or an intensive team for care. 
 
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 slurred speech and hypertension. Your medical conditions 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. While the medical record documents a 
need for physical and occupational therapy, there is no need for an intensive rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Febuxostat 40 mg tablets. 
 
You asked the Plan to pre-approve Febuxostat. You say that Febuxostat is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Febuxostat 40 mg tablets.  
 
Benefits for Febuxostat may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care provided from December 
15, 2020, forward. 
 
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided, this patient does not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of December 15, 2020, 
forward and could have been treated in a lesser restrictive setting as the patient was not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations and was not showing any behaviors or aggression being 
cooperative and compliant while not showing any acute threats to safety. The patient was internally 
preoccupied according to record. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care provided from December 15, 2020, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 27, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you went for a consultation but 
didn't get any answers. You say that you shouldn't have to pay double. 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 $35 
copayment for in-network physician specialist services.  
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor?s office visits" benefit category. The records show that an 
office visit with a specialist was provided. 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 office 
visit provided on July 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for injections (20611) of Methylprednisolone 
acetate (J1030) and Ropivacaine (J2795) received on August 5, 2020. 
 
You asked the Plan to waive the cost-sharing for injections of Methylprednisolone and Ropivacaine. You say 
that you shouldn't be responsible for 2 dates of service because the first provider did not have the proper 
equipment. The Plan denied your request. The Plan says the correct cost-sharing 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 a $30 
copayment for each specialist visit for Medicare-covered services and 20% coinsurance for Medicare-covered 
Part B drugs.  
 
You have been asked to pay a $30 copayment for injections of Methylprednisolone and Ropivacaine. Injections 
of Methylprednisolone and Ropivacaine fall within the "Physician/Practitioner services, including doctor?s 
office visits" benefit category. You have also been asked to pay $1.22, or 20% of the Medicare-allowed amount 
of $6.09, for Methylprednisolone, and $0.02, or 20% of the Medicare-allowed amount of $0.08, for 
Ropivacaine. 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 cost-sharing for injections (20611) of Methylprednisolone 
acetate (J1030) and Ropivacaine (J2795) received on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care. 
 
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the patient requires active 
treatment. 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 inpatient mental health care. 
Our physician reviewer found based upon review the records provided for the admission does not meet the 
criteria for continued acute inpatient mental health treatment for the dates in question as you were not shown 
to be a danger to yourself or others. You were not showing any auditory or 
visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for restorative procedure (D2999), and waive the copayments for 
endodontic therapy, molar (D3330), post and core in addition to crown, indirectly fabricated (D2952), and 
crown-porcelain fused to nigh noble metal (D2750) provided on May 11, 2020. 
 
You asked the Plan to pay for restorative procedure, and waive the copayments for endodontic therapy, molar, 
post and core in addition to crown, indirectly fabricated, and crown-porcelain fused to nigh noble metal. You 
say that the services should be covered. The Plan denied your request. The Plan says the service was denied 
and cost shares were applied 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. Restorative procedure 
(D2999) is not a covered benefit and there is a cost share for endodontic therapy, molar (D3330), post and core 
in addition to crown, indirectly fabricated (D2952), and crown-porcelain fused to nigh noble metal (D2750). 
 
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. Specifically, Restorative procedure (D2999) is not a covered benefit 
and the cost shares for endodontic therapy, molar (D3330), post and core in addition to crown, indirectly 
fabricated (D2952), and crown-porcelain fused to nigh noble metal (D2750) were applied correctly. Therefore, 
we decided that the Plan does not have to pay for restorative procedure (D2999), and waive the copayments for 
endodontic therapy, molar (D3330), post and core in addition to crown, indirectly fabricated (D2952), and 
crown-porcelain fused to nigh noble metal (D2750) provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for physician services provided to the enrolle and billed 
under codes 96413 and 96375. 
 
You asked the Plan to pay for codes 96413 and 96375. You say that this claim should be paid. The Plan denied 
your request. The Plan says code 96375 can only be paid when the primary code, 96413, is allowed on the 
claim. The Plan says that code 96413 was denied because the records submitted do not contain enough detail to 
support the billed charges. The Plan states the time over which the infusion was administered is not 
documented and therefore the service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide medical records to support the services 
billed. In this case insufficient medical records were submitted to support the billing of code 96413. In 
addition, code 96375 is not eligible for payment without code 96413. Medicare billing criteria are not met. 
Therefore, we decided that the Plan does not have to pay for to pay for physician services provided to the 
enrollee and billed under codes 96413 and 96375.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided.  
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you didn't have a telephone 
visit with the provider. You say that charge should be canceled. 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 $45 for 
each Medicare-covered specialist office visit. Covered services include certain telehealth services, including 
follow-up care from in-person consultation, diagnosis, or treatment. You have the option of receiving these 
services either through an in-person visit or via telehealth. If you choose to receive one of these services via 
telehealth, then you must use a network provider that currently offers the service via telehealth. 
 
 
  
 
 
You have been asked to pay a $45 for the telehealth visit. The telehealth visit falls within the 
"Physician/Practitioner services, including doctor?s office visits" benefit category. The records show that the 
telehealth visit was for a follow-up for bronchiectasis, chronic cough and hypoxemia. 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 telehealth visit provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim caries arresting medicament application (D1354 x 
2) provided on August 20, 2020. 
 
You asked the Plan to pay for the dental service. You say that your dentist advised that this was the best course 
of treatment due to your age and multiple caries. The Plan denied your request. The Plan says interim caries 
arresting medicament application is not listed as a covered service. 
 
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 
interim caries arresting medicament application (D1354 x 2) provided on August 20, 2020.
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 have been in constant pain for months. The Plan 
denied your request. The Plan says your medical complexity of care is low, and you do not require an 
interdisciplinary team approach for rehab care. 
 
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 shoulder replacement surgery. Your medical conditions 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. While the medical record documents a 
need for physical and occupational therapy, there is no need for an intensive rehabilitation 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.