Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 1, 2019 through 
October 3, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found this patient has sufficient morbidity with unstable angina in a liver transplant patient with 
chronic kidney disease (CKD) meet admission criteria. The finding of multivessel disease also substantiates the 
acuity and seriousness of condition on presentation. The admission criteria are met based on chronic conditions 
and life threatening acute illness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 1, 2019 through October 3, 2019.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve jaw surgery.
You asked the Plan to pre-approve jaw surgery. 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. 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 jaw surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a review of the enrollee's dental records indicate that the services appealed for the most part involve the care of teeth or structures directly supporting the teeth. These services are not a covered expense as noted in Medicare's Evidence of Coverage. The supplemental coverage also does not cover these services with the exception of extractions. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of jaw surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve jaw surgery.
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 IRF 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 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 patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional level 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on April 16, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you feel the Medicare Part B drug charges should be included in the copayment. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on April 16, 2020. The allowed amount is $182.86 and 20% of that is $36.57. You have been asked to pay the total coinsurance amount of $36.57 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on April 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the mental health visits provided from 
March 14, 2019 to December 26, 2019. 
 
You asked the Plan to reduce the copayments for the mental health care visits. You say that you would like the 
copayment reduced. You say you did not understand that mental health practitioners have a $40 copayment. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 
copayment for each Medicare-covered individual therapy session.  
 
You have been asked to pay a $40 copayment for each of the mental health care visits. The mental health care 
visits fall within the "Outpatient Mental Health 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 reduce the 
copayments for the mental health visits provided from March 14, 2019 to December 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility for the
enrollee.
You asked the Plan to pre-approve the admission. You say that it is medically necessary for the enrollee to
receive inpatient psychiatric services. The Plan denied your request. The Plan says there is no imminent risk to
others or self.
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 the admission. Our reviewer says that
the requested services are not medically reasonable or necessary. Our physician reviewer found it is not
expected that the enrollee would improve in a reasonable period of time beyond the dates in question as he was
not showing any dangerousness to self or others, intermittent auditory no visual hallucinations and no abnormal
behaviors. The enrollee was compliant with treatment. It did not appear medically necessary and reasonable to
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the
dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors.
The health plan's denial of continued inpatient psychiatric services appears appropriate.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient psychiatric facility for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery received on January 22, 
2020. 
 
You asked the Plan to waive the copayment for the surgery. You say that you were told this would be covered 
in full. The Plan denied your request. The Plan says the copayment was applied correctly according to your 
benefits and the services rendered. 
 
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 $600 
copayment for outpatient surgery.  
 
You have been asked to pay a $600 copayment for the surgery. The surgery falls within the outpatient surgery 
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 outpatient surgery received on 
January 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Micra Implant pacemaker (33274). 
 
You asked the Plan to pre-approve a Micra Implant pacemaker. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a Micra Implant pacemaker. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance the documentation does not indicate the enrollee's 
heart rate is significantly elevated nor does it indicate the enrollee is unable to tolerate additional rate control 
medication, if needed. An atrioventricular (AV) nodal ablation with pacemaker placement would be indicated 
only if persistent tachycardia were present in spite of maximum tolerated rate control medication. In fact, 
leadless pacemaker placement may precipitate recurrent heart failure/left ventricular (LV) dysfunction by 
causing dysynchrony induced by a single chamber leadless device. Therefore the records do not document the 
medical necessity for AV nodal ablation and leadless pacemaker placement at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Micra Implant pacemaker have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Micra Implant pacemaker (33274).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 
25, 2019. 
 
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom 
profile. The Plan denied your request. The Plan says the documentation did not contain evidence of a 
relationship with the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We find that the drug testing is not supported in the medical record. The records provided do not show that the 
testing was individualized to identify specific non-prescribed medications or illicit substances. The records 
provided do not document concerns based on clinical review and judgement for the date of service at issue. 
Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing 
provided on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the periodontal scaling and root planing
(D4341), gingival irrigation-per quadrant (D4921), and the unspecified periodontal procedure (D4999)
provided on February 11, 2020.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are
not a covered benefit under your contractual policy.
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 services provided are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for
the periodontal scaling and root planing (D4341), gingival irrigation-per quadrant (D4921), and the unspecified
periodontal procedure (D4999) provided on February 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on November 26, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 80053, 85025, 80061, 82306, 84443 (1 Unit) and 
Healthcare Common Procedure Coding System (HCPCS) G0103 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the denied CPT codes are not supported in the medical record. Specifically, the place of service on 
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects 
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 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 pay for lab services provided to the enrollee 
on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health.
You asked the Plan to pre-approve inpatient behavioral health. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria has not been met.
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 inpatient behavioral health. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found based upon review of the records provided, you do not meet the criteria for
treatment in an acute inpatient mental health treatment beyond the date in question of August 1, 2020 forward.
You could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal
ideation with no plan, auditory or visual hallucinations and was not showing any behaviors. You were being
cooperative and compliant.
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 behavioral health have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient behavioral health.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on December 5, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on December 5, 2019.