Persius/hicric huggingface dataset:
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 your rehabilitation needs at present are not complex and do not require 
an interdisciplinary approach with multiple specialists to oversee your rehabilitation 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 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 does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  
 
You were admitted for surgical repair of hip fracture. Medical problems are stable. 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 record supports a 
need for physical and occupational therapy, there is no documented 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 
(CPT Code 22514). 
 
You asked the Plan to pre-approve the services. You say that you are in a lot of pain and your life depends on 
this surgery. The Plan denied your request. The Plan says you have not had magnetic resonance imaging (MRI) 
or bone scan/single-photon emission computed tomography (SPECT)/computed tomography (CT) within the 
previous thirty (30) days. 
 
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 physician reviewer 
found the MRI does not show evidence of an acute compression fracture. Kyphoplasty is not needed and not 
likely to help back pain in this case. 
 
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 percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar (CPT Code 22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 23, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on April 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion tray (A4314) and drainage bag (A4357) 
provided on December 12, 2019. 
 
You asked the Plan to pay for the insertion tray and drainage bag. You say that you would like reconsideration 
because the member was in a Part B stay. The Plan denied your request. The Plan says the procedure codes 
A4314 and A4357 were billed in a Place of Service 31 Skilled Nursing Facility and an institution may not be 
considered your home if it is a Skilled Nursing Facility for Part B benefits. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the insertion tray and drainage bag was used in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pay for the insertion tray (A4314) and drainage bag (A4357) provided on 
December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown provided on February 28, 2020. 
 
You asked the Plan to pay more for the crown. You say that you weren't told that you couldn't have an out-of-
network dentist. 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 50% 
of the allowed amount for your covered major dental services from an out-of-network provider. You are 
responsible for the remaining amount. Therefore, we decided that the Plan does not have to pay more for the 
crown provided on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 17, 2020 by a 
non-network 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 a non-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 referring provider is not a 
network provider with the Plan. The Plan has network providers available who can provide the items/services 
at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on February 17, 2020 by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy and cone beam CT capture provided on 
April 23, 2020. 
 
You asked the Plan to pay for the endodontic therapy and cone beam CT capture. You say that you should have 
been notified endodontics were not covered by your plan. You say that the procedure should be 50% covered. 
The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 
endodontic therapy and cone beam CT capture provided on April 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy in the home health setting. 
 
You asked the Plan to pre-approve the physical therapy in the home health setting. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the enrollee appears to be at or 
near the level of functioning compared to before therapy services began. The Plan says that the enrollee 
appears to have caregivers available who can help with daily living tasks. The Plan says that the enrollee 
should be able to continue therapy at a lower level of care, such as an outpatient setting or with a home exercise 
plan. The Plan says that the records do not support the need for a skilled physical therapist to make more home 
visits at this time. 
 
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 the physical therapy in the home health 
setting. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found, 
based on the documentation provided, the enrollee no longer requires home physical therapy. The enrollee is 
ambulating more than 100 feet and tending to functional transfers with minimal supervision.  As a practical 
matter, the enrollee's ongoing care needs can be provided 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 the physical therapy in the home health setting have not been met. Therefore, 
we decided that the Plan does not have to pre-approve physical therapy in the home health setting.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on the removal of a leg bone lesion 
(27635) provided on August 15, 2019. 
 
You asked the Plan to pay for surgical assistant services on the removal of a leg bone lesion. You say that a 
surgical assistant is allowed on this service. The Plan denied your request. The Plan says a surgical assistant is 
not covered for this service. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
27635. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for surgical assistant services on the removal of 
a leg bone lesion have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
assistant services on the removal of a leg bone lesion (27635) provided on August 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusion therapy received on March 5, 
2020. 
 
You asked the Plan to waive the copayment for the therapy. You say that you cannot afford this. The Plan 
denied your request. The Plan says the cost-sharing was 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 $325 
copayment for outpatient services.  
 
You have been asked to pay $184.95 for the therapy. The therapy falls within the outpatient services benefit 
category. The usual copayment for this service is $325, but the allowed amount for the service is less than the 
copayment. 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 infusion therapy received on March 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ultrasound provided by an out-of-
network provider on April 22, 2020. 
 
You asked the Plan to waive the coinsurance for an ultrasound. You say that this was urgent and you did not 
have time to find an in-network provider. The Plan denied your request. The Plan says the correct coinsurance 
has been 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 50% 
coinsurance for outpatient diagnostic tests/out-of-network.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for an ultrasound. The total allowed 
amount is $591.16. The total amount you are being asked to pay is $295.58 ($591.16 x 50% = $295.58). The 
correct coinsurance has been applied to the service that was provided. An ultrasound falls within the outpatient 
diagnostic tests/out-of-network 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 
an ultrasound provided by an out-of-network provider on April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on December 11, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing 
rendered on December 11, 2019.
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 for the enrollee. 
 
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 the member does not have acute comorbidities requiring ongoing 
medical assessment and management. 
 
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 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 management of a hip 
fracture. Medical problems are stable. 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 record supports a need for physical and occupational 
therapy, there is no documented 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. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is expected to be on a 
ventilator for at least 25 days and needs to be monitored when coming off the ventilator. You say that the 
enrollee is medically stable to transfer to an acute long-term facility. The Plan denied your request. The Plan 
says the services needed could be provided in another setting. 
 
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 reviewer 
says that long term acute care hospitals and acute care hospitals are licensed to provide the same level of care. 
Our physician reviewer found that the enrollee can remain at the current acute care hospital until no acute 
services are required. 
 
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 LTACH services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from December 25, 2019 through 
January 2, 2020. 
 
You asked the Plan to pay for the inpatient stay. You say that the enrollee refused hospice. You say that the 
claim should be processed for payment. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 25, 2019. The services in began before the end of 
that month. Therefore, we decided that the Plan does not have to pay for the inpatient stay provided from 
December 25, 2019 through January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care services provided 
March 4, 2020 to March 7, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that You can afford $500. 
You don't understand why your share is so high. Please reduce your cost share on this cost plan to $500. The 
Plan denied your request. The Plan says the claim was processed correctly and the correct copayment was 
applied according to the plan benefits. 
 
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 $210 per 
day, days 1-4, $0 per day for days 5-90 for Inpatient hospital care.  
 
You have been asked to pay $630 for the inpatient hospital care. The services fall 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 inpatient hospital care services 
provided March 4, 2020 to March 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair, group 2 standard, captains chair, 
patient weight capacity up to and including 300 pounds (CPT Code K0823) and power wheelchair accessory, 
u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat (E2365), for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not 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 DME. Our physician reviewer 
found the patient is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, 
standard manual wheelchair, or use of a walker). Therefore, this request is 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 
300 pounds (CPT Code K0823) and power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel 
cell, absorbed glassmat (E2365), for the enrollee.