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 based on the documentation provided, the health plan?s denial should be upheld. The 
patient does not require the intensity of services provided at an IRF. Specifically, the patient is not shown to 
require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The patient's 
care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance cholangiopancreatography (MRCP) 
billed with code S8037. 
 
You asked the Plan to pre-approve code S8037. You say that the clinical documentation provided supports the 
need for the service in dispute. The Plan denied your request. The Plan says an MRCP should be reported with 
one standard MRI procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate HCPCS/CPT code. The rules say that HCPCS/CPT codes 
with a status indicator of I are not recognized by Medicare and will not be paid. Medicare uses another code for 
reporting of, and payment for, these services. 
 
We looked at the file and Medicare rules. We found that payment for code S8037 is not supported. Specifically, 
code S8037 has a status indicator of I and will not be paid for by Medicare. This service should be reported 
with a code that is recognized by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance cholangiopancreatography (MRCP) billed with code S8037.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a wrist arthroplasty and tendon transfer. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has had no relief of symptoms. The 
Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee presents with progressively 
worsening grade eight out of 10 right thumb pain with associated swelling and deformity. Pain interferes with 
gripping and pinching, and disrupts sleep. Clinical exam findings are consistent with reported radiographic 
evidence of moderate right first carpometacarpal joint osteoarthritis. She has tried rest, splinting, activity 
modification, medications, and cortisone injections without sustained relief. The enrollee has failed reasonable 
conservative treatment with progressive pain and dysfunction. Therefore, the requested surgical intervention 
would be considered the standard of care for the enrollee's medical condition, and is medically reasonable and 
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 been met. Therefore, we decided that the Plan has to pre-
approve a wrist arthroplasty and tendon transfer.  
 
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 laboratory services provided on April 22, 2020. 
 
You asked the Plan to pay for the laboratory 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 
laboratory services. 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 laboratory services provided on April 22, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging; skull base to mid-thigh (CPT Code 78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the patient is waiting for prostate cancer surgery 
and cancer is very aggressive. You state without the scan one could not know whether to do surgery or chemo. 
The Plan denied your request. The Plan says that the requested study is not supported for the first staging of 
prostate (a gland that surrounds the neck of your bladder) cancer. The Plan states the records show that the 
study was requested for this reason. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our physician reviewer 
found based on current recommendations, it would be medically acceptable to perform PET scan in men with 
high and very high risk disease, as in this enrollee. If results of conventional imaging, such as bone scan in this 
case, are negative or equivocal, next-generation imaging with F-18 fluciclovine PET/CT or Axumin PET/CT is 
medically appropriate in order to assess distant metastases. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT Code 78815).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DME to be provider by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says there are providers in-network that can provide this DME. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the DME to be provider by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer to SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary 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 transfer to SNF care.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the 
enrollee can safely receive the services needed 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 documentation does not support any need for IRF care for the diagnosis and lack of 
medical complexity. The enrollee is generally medically stable with no evidence of need for a physical 
medicine and rehabilitation physician's monitoring 3 times a week or needs acute rehab nursing care. While she 
may benefit from continuing physical therapy and occupational therapy at home or safety education, there is no 
documented 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. Admission to an IRF is not 
medically necessary based on lack of medical complexity and current functional status in mobility and 
activities of daily living. The enrollee's rehab needs could be met at an alternate, low intensity level setting 
such as in home-with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral Ondansetron. 
 
You asked the Plan to pre-approve the Ondansetron. The Plan denied your request. The Plan says this drug is 
not covered under the enrollee's 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 oral Ondansetron.  
 
Benefits for the Ondansetron 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested device is necessary to 
continue quality of care treatment. The Plan denied your request. The Plan says there is no evidence that the 
enrollee has failed all forms of more conservative treatments first. 
 
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 spinal cord stimulator. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have an evidence based indication for SCS trial. She also has not had a 
trial of intra-thecal opiates or a psychological evaluation. The documentation provided does not support that a 
spinal cord stimulator is 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Surgery
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. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a diagnostic test provided by a participating provider on April 6, 2020 to April 8, 2020.

You asked the Plan to waive the coinsurance for a diagnostic test. You say that your copayment should only be $45 or $65. 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 20% coinsurance for outpatient diagnostic tests/in-network/diagnostic procedures and tests/outpatient hospital. 

You have been asked to pay a 20% coinsurance of the allowed amount for a diagnostic test. The total allowed amount is $3,715.52. The total amount you are being asked to pay is $743.11 ($3,715.52 x 20% = $743.11). These services were provided in an outpatient hospital facility; therefore, the correct 20% coinsurance has been applied. A diagnostic test falls within the outpatient diagnostic tests/in-network/diagnostic procedures and tests/outpatient hospital 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 diagnostic test provided by a participating provider on April 6, 2020 to April 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 9, 2020. 
 
You asked the Plan to pay for dental services. You say that there was no mention that you didn't have out-of-
network benefits. You say that the provider is not out-of-network. The Plan denied your request. The Plan says 
out-of-network dental 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care received from May 27, 2020, 
to May 28, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says you were stable during a short stay. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the evidence from signs, symptoms, labs, and imaging suggested that you were no 
longer experiencing an acute event and did not require acute care services which would require a two-midnight 
stay in the hospital. You were stable and had no condition which required intervention. The consultations and 
short-term monitoring could have taken less than two midnights in the hospital. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care received from May 27, 2020, to May 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 7, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that this testing is not offered by in-network 
laboratories. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the 
Plan. 
 
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 August 7, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 3, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service requires 
the billing of code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 6, 2020. 
 
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 February 6, 2020.