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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to the hospital for shortness of breath and was treated for 
congestive heart failure and COPD exacerbation. Her medical problems are now stable and she has no complex 
nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 
the medical records show the enrollee is from surgery. There are no indications the enrollee would require 
more than 24 days of acute care services. The enrollee does not require services at the LTACH that are not 
already available at the current facility. The enrollee can continue current treatment at the current facility. 
Medicare coverage criteria for transfer are not met. 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 long term acute care hospital 
(LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee surgery and inpatient admission. 
 
You asked the Plan to pre-approve knee surgery and inpatient admission. 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 knee surgery and inpatient admission. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records do not show that the enrollee has had adequate physical 
therapy (PT) for knee pain. Revision surgery not needed 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 knee surgery and inpatient admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve knee surgery and inpatient admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no clinical evidence to support the medical necessity of this 
examination or that the member meets Medicare criteria for continued PT therapy services 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the medical records provided do not meet the requirements listed in 
the LCD for Medicare coverage for 10 additional physical therapy visits. The requested additional therapy is 
not generally accepted as specific and effective therapy for the patient's condition. The patient has a chronic 
pain issue. The patient has made some progress in ambulatory tolerance, but the records do not indicate the 
patient requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment. 
Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a 
therapist. The patient has had extensive therapy and an additional ten (10) sessions of therapy would be 
excessive for the patient's condition. The notes indicate that the patient has routine spasms and persistent pain 
after 2 minutes of ambulation. The note indicates patient is hesitant to perform step ups and sit to stand due to 
increased pain. The documentation does not reveal whether the patient has seen their physician recently as it 
appears that pain is limiting her progress in therapy and ability to fully participate. The requested services are 
not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the patient's current condition or to 
prevent or slow further deterioration. 
 
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 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facelift (15825, 15826). 
 
You asked the Plan to pre-approve a facelift. 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 cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 facelift. Our reviewer says that the 
services are not medically necessary. Our reviewer found the documentation does not support that the 
requested facelift (Rhytidectomy) is medically reasonable and necessary for you. The medical necessity of neck 
lift surgery and frown line surgery has not been demonstrated 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 a facelift have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a facelift (15825, 15826).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, any joint of lower extremity; without contrast 
material (CPT Code 73721). 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has left hip pain, known/suspected labral 
tear. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
based on the documentation provided, the health plan's denial should be upheld. The enrollee is noted to have 
back pain with radiculopathy, and hip pain. The enrollee has documented spine and disc disease on imaging.  
Lower extremity EMGs were ordered, but not submitted for review. No plain radiographs of the hips have been 
submitted for review. While it is possible that the enrollee has both disease in their spine and in their hip, it 
does not appear that the spinal disease has been fully explored or that basic imaging of the hips has been 
performed. Therefore, the requested MRI of the hip is not shown to be currently medically necessary or 
reasonable. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, any joint of lower extremity; without contrast material (CPT Code 73721).
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 IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for IRF admission are not 
met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of 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 
documentation does not support that the enrollee's functional status requires or can tolerate an intensive 
rehabilitation therapy program provided in an IRF. Medicare coverage criteria are not met.  
 
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: Favorable

We decided that the Plan has 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 that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the records do indicate that there are significant, or complex medical/nursing issues that are not best 
addressed at a skilled nursing facility (SNF) level of care, considering the enrollee's acute stroke and need for 
determining etiology behind stroke, and given the need for close registered nurse (RN) and doctor management 
and supervision of neurological status. Ongoing pain medication and other medication management, skin care, 
neurological monitoring, and daily intensive multidisciplinary therapy are best afforded at an IRF. The member 
is mostly MODERATE to MAX assist for functional transfers and ADL?s and an intensive rehab course will 
allow for measurable/significant gains to be attained within a reasonable, and predicted period.  An IRF 
intensity is warranted and a SNF is not the best level of care following this acute, significant neurological 
injury (stroke). There is a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pre-diagnostic testing, topical fluoride, and core buildup 
for teeth 2 and 20. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 pre-approve pre-
diagnostic testing, topical fluoride, and core buildup for teeth 2 and 20.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH transfer is medically necessary. 
The Plan denied your request. The Plan says Medicare coverage criteria for transfer to LTACH are not met. 
 
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 based on the medical records you are not stable for transfer at this time. You do not 
require services at the LTACH that are not already available at the current facility.  Therefore, this request for 
LTACH services will be considered not medically necessary. You can continue current treatment at the current 
facility until your medical condition is stable. 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 long term acute care hospital 
(LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 8, 2020 to April 16, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that it was the doctor's fault 
that this inpatient stay was needed. The Plan denied your request. The Plan says the correct copayment 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 $325 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-5. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay is $1,625 ($325 x 5 days = 
$1,625). An inpatient hospital stay falls 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 an inpatient hospital stay provided by a participating provider on 
April 8, 2020 to April 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on December 11, 2019. 
 
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 billed are not supported by the documentation. 
 
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 should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier must 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 December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic laboratory services provided on July 29, 2019. 
 
You asked the Plan to pay for the genetic laboratory services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the genetic laboratory 
services provided on July 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the right knee (73562) provided on April 11, 
2020. 
 
You asked the Plan to pay for the x-ray. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis.  
 
We looked at the file and Medicare rules. The file shows that the x-ray of the knee was billed with one or more 
diagnosis codes that are inappropriately coded. Medicare rules say that some ICD-10-CM codes indicate 
laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report 
unspecified, or left and right diagnosis codes when a more specific, in this case; a code for the right side is 
available. Therefore, we decided that the Plan does not have to pay for the x-ray of the right knee (73562) 
provided on April 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services rendered on March 
9, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you never had to pay for similar 
testing before. The Plan denied your request. The Plan says the copayment 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 $20 
copayment for lab services performed by a provider other than your primary care physician.  
 
Review of the file shows that you received laboratory services on March 9, 2020. Per the contract with the 
Plan, there is a $20 copayment for lab services performed by a provider other than your primary care physician. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the 
Medicare allowed amount for these services was $17.44. Given that the allowed amount was less than the $20 
copayment, you have been asked to pay $17.44 for these services. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered 
on March 9, 2020.