Persius/hicric huggingface dataset:
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 exceeds the criteria for an 
LTACH admission. You say that the enrollee should be transferred as it is the appropriate level of care. The 
Plan denied your request. The Plan says the enrollees current needs are being met in the acute 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 
physician reviewer found that there is no evidence that the enrollee requires services that are not currently 
available. Our reviewer says 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: 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 considering the degree of illness and baseline 
functional status, the enrollee will benefit from aggressive therapy. You say that the enrollee will then return to 
home at a higher level of function and the ability to care for herself. The Plan denied your request. The Plan 
says care can be received in another setting. 
 
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 that 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 acute IRF admission and services.
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 enrollee's therapy needs can be provided at a lower level of 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 
patient is currently medically stable on oral medications for blood pressure and pain and there is no evidence of 
complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or 
acute rehab nursing care. While the enrollee may benefit from continuing physical therapy (PT) and 
occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours 
per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The 
enrollees rehab needs can be met in a lower intensity alternate setting. 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 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 it appears therapy services could be provided at alternative level of 
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 
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. The enrollees care 
needs can be met at a lower level of care. 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.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. 
 The Plan denied your request. The Plan says that this is not recommended for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that the 
documentation supports that the Orthovisc injections are medically reasonable and necessary and safe and 
effective for treatment of this enrollees right knee osteoarthritis. Our physician reviewer found the enrollee has 
a history of chronic right knee pain and clinical exam findings have been consistent with right knee 
osteoarthritis. She has failed to achieve adequate improvement with conservative treatment, including activity 
modification, medications, physical therapy, and corticosteroid injections. She is not able to proceed with a 
recommended total knee arthroplasty due to obesity. Current evidence based medical guidelines state that 
medical evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in 
some patients. A trial of Orthovisc injections is reasonably indicated for treatment of this enrollees knee pain 
given the failure of comprehensive conservative treatment, worsening pain, and preclusion from surgical 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have been met. Therefore, we decided that the Plan has to pre-
approve Orthovisc (J7324).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 21, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 pay for the Guardant360 panel rendered on April 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided 
September 12, 2018 to September 13, 2018. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $360 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $360 copayment ($360 x 1 day) for the inpatient hospital care 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 inpatient hospital care provided September 12, 2018 to 
September 13, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from January 15, 2020 through January 21, 2020.

You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for post-stabilization care. Our physician reviewer found based on the above objective data from the ED assessment, the patient did not have any significant signs of sepsis nowhere in the documentation did the treating physicians state that the patient was not stable to transfer. Based on the documentation provided, the patient was stable for transfer on January 15, 2020 at 9:28 am.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from January 15, 2020 through January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services provided in a memory care unit. You say that you rely on 
the patient's facility to obtain proper authorizations. The Plan denied your request. The Plan says neither the 
provider of services nor the facility requested authorization for these non-plan services.  Unauthorized non-plan 
care is not covered. 
 
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 January 6, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile testing provided on 
December 12, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine the optimal treatment for the enrollee. The Plan denied your request. The Plan says the denial of 
payment for this testing is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service December 12, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile testing provided on December 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy provided by an out-of-
network provider on January 21, 2020 to March 13, 2020. 
 
You asked the Plan to waive the deductible for physical therapy. You say that you do not agree with your 
deductible. The Plan denied your request. The Plan says the correct deductible has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible for outpatient rehabilitation services/out-of-
network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
rehabilitation services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1,000 deductible for outpatient rehabilitation services/out-of-network. This cost sharing 
is a contractual obligation that had not been met at the time physical therapy was received on January 21, 2020 
to March 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for physical 
therapy provided by an out-of-network provider on January 21, 2020 to March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for amalgam - two surfaces, primary or permanent (D2150) and 
amalgam - three surfaces, primary or permanent (D2160) provided from March 10, 2020 through March 25, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the 
plan. 
 
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. 
 
Review of the file show that you received D2150 and D2160 from March 10, 2020 through March 25, 2020. 
Your EOC states, that you have a $750 limit. Furthermore, D2150 and D2160 are listed in your dental 
addendum as being covered under the $1,000 maximum benefit which you do not have. Therefore, we decided 
that the Plan does not have to pay for amalgam - two surfaces, primary or permanent (D2150) and amalgam - 
three surfaces, primary or permanent (D2160) provided from March 10, 2020 through March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient lab work provided by a 
participating provider on June 3, 2020. 
 
You asked the Plan to waive the deductible for outpatient lab work. You say that you do not agree with this 
deductible. The Plan denied your request. The Plan says the correct deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible that must be met before cost sharing amounts are 
applied.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible that 
that must be met before cost sharing amounts are applied. This cost sharing is a contractual obligation that had 
not been met at the time outpatient lab work was received on June 3, 2020. Therefore, we decided that the Plan 
does not have to waive the deductible for outpatient lab work provided by a participating provider on June 3, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chest X-rays (71046) and a breathing 
capacity test (94010) performed on February 20, 2020. 
 
You asked the Plan to waive the copayments for chest X-rays and a breathing capacity test. You say that you 
were not informed of the copayments prior to the services. The Plan denied your request. The Plan says the 
correct copayments were 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 Medicare-covered standard X-ray service and a $30 copayment for Medicare-covered non-
radiological diagnostic services.  
 
You have been asked to pay $60, or a $30 copayment each, for chest X-rays and for a breathing capacity test. 
Chest X-rays and a breathing capacity test fall 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 copayments for chest X-
rays (71046) and a breathing capacity test (94010) performed on February 20, 2020.  
 
Your complaint about not being informed by the provider of the copayments prior to the services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 19, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed 
with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service March 19, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 12, 2018. 
 
You asked the Plan to pay for the physician's services. 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 physician's services provided on December 12, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health physician services provided to the enrollee on 
February 17, 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 Medicare billing criteria are not met. The Plan states insufficient medical records were 
submitted to support the services billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and provide sufficient medical records to support 
the services billed.  
 
In this case, insufficient medical records were submitted to support the services billed. Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel rendered on August 19, 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 must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are 
non-covered. 
 
The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. 
Furthermore, this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay 
for the CYP panel rendered on August 19, 2019.