Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided March 24, 2020 to March 25, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that coverage criteria was not met. 
 
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 given the enrollee's symptoms, risk factors, and abnormal stress test, it was reasonable to expect 
inpatient care to span two midnights. 
 
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 March 24, 2020 to March 25, 2020.  
 
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: 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 these services are medically necessary. 
The Plan denied your request. The Plan says that the member's needs can be met in a lower level of care, such 
as in a skilled nursing facility or at home with home health care. 
 
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. The patient 
appears to be improving and requires additional short term acute care services (less than 25 days) for additional 
treatment and monitoring. The patient does not require services at the LTACH that are not already being 
provided at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitamin D test (82306) provided on June 9, 2020 
 
You asked the Plan to pay for a vitamin D test. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has established limited coverage for 
CPT codes 82306 for specific diagnosis codes.  If a covered diagnosis is not on the claim, the edit will 
automatically deny the service as not medically necessary 
 
We looked at the file and Medicare rules. The diagnosis code on the claim, I10, is not a covered diagnosis code 
for the service at issue. Based on this information, we decided that Medicare rules for coverage of a vitamin D 
test have not been met. Therefore, we decided that the Plan does not have to pay for a vitamin D test (82306) 
provided on June 9, 2020.
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 ongoing skilled services 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 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient'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 patient's 
functional status requires or can fully tolerate an intensive rehabilitation therapy program provided in an IRF 
given his symptoms of orthostasis. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of skin and tissue (11042) provided on June 18, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the removal of skin and tissue. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 removal of skin and tissue (11042) provided 
on June 18, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair.You asked the Plan to pre-approvea power wheelchair. You say that the enrollee does not have the ability to independently reposition himself.The Plan denied your request. The Plan says there is no information on why the enrollee needs a new power wheelchair.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that the enrollee currently has a powerwheelchair. The records show that the Plan approved repairs to the enrollee's current chair. The documentation in the case file does not show that the repairs have been completed, or that the chair is beyond repair. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approvea power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
You asked the Plan to pre-approve Vascepa. You say that the enrollee has coronary artery disease without 
angina pectoris. The Plan denied your request. The Plan says the medication does not fall under Part B. 
 
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 Vascepa.  
 
Benefits for Vascepa 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on July 1, 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 services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no documentation to support that the anesthesia meets the 
Medicare criteria for coverage. The Plan made several attempts to obtain medical records for these services but 
they were not received from the non-contracted provider. 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 anesthesia services rendered on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) on December 
24, 2018. 
 
You asked the Plan to pay for hospital discharge day management. You say that you would like reconsideration 
based on the medical records provided. The Plan denied your request. The Plan says the submitted discharge 
summary does not support hospital discharge day management of more than 30 minutes was performed. The 
submitted documentation does not include the time spent providing this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes.  
 
We find that CPT code 99239 is not supported in the medical record. We looked at the file and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the discharge management services 
have not been met. Specifically, the record does not show that more than 30 minutes of hospital discharge day 
management services were provided. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) on December 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213), injections, tendon sheath, 
ligament (20550) and injection, triamcinolone acetonide (J3301) provided on May 19, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for office visit, triamcinolone acetonide injection and tendon sheath injection. You 
say that you were told your doctor was in-network. The Plan denied your request. The Plan says prior 
authorization must be obtained for serviced rendered by an out-of-network provider. 
 
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 outpatient office visit (99213), injections, 
tendon sheath, ligament (20550) and injection, triamcinolone acetonide (J3301) provided on May 19, 2020 by 
an out of network (OON) provider.  
 
Your complaint about receiving potential misinformation from the Plan 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee does not need a skilled level of care.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral and ophthalmic medications. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee has been on a restorative nursing program, and requires staff assist with mobility and care. There are no identifiable skilled therapy service needs. He does not require skilled services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) 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 this facility will help the enrollee get back to where 
she was prior to the fall. The Plan denied your request. The Plan says that the enrollee could not tolerate 3 
hours therapy, 5 times a week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an admission for SNF services. 
 
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says you do not 
meet Medicare guidelines for approval of admission to skilled nursing facility. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found that based on the medical records 
provided there is documentation that you require skilled nursing services, but there is no compelling argument 
in the records as to why you require transfer from the acute inpatient rehabilitation facility to a skilled nursing 
facility for the nursing care. Based on the medical records provided there is documentation that you require 
skilled therapy services, but there is no compelling argument in the records as to why you require transfer from 
the acute inpatient rehabilitation facility to a skilled nursing facility for the therapy treatments. Based on the 
medical records provided daily skilled services are required. Based on the medical records provided you do not 
require the services on an inpatient basis. There is no compelling argument in the records as to why you require 
transfer from the acute inpatient rehabilitation facility to a skilled nursing facility for the nursing and therapy 
treatments.  
 
 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an admission for SNF services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a 
participating provider on May 19, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you have never had a 
copayment for this before. You say that you feel like you are being discriminated against because you have 
dense breasts. 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 $155 
copayment for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay a $155 copayment for a diagnostic ultrasound. Services were provided that went 
beyond preventative care; therefore, the correct copayment has been applied. A diagnostic ultrasound falls 
within the outpatient diagnostic tests/other outpatient diagnostic tests 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 a diagnostic ultrasound provided by a participating provider on May 
19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the nerves of the 
sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve the SI joint RFA procedure. You say that you feel this should be covered to 
help treat your pain. The Plan denied your request. The Plan says this service is not covered by Medicare as it 
is deemed investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA of the SI joint nerves is investigational and 
is not covered by Medicare. 
 
Although this may be appropriate, Medicare does not currently find the evidence sufficient to consider this 
treatment reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation (RFA) of the nerves of the sacroiliac (SI) joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is not ambulating yet, but is very cooperative and motivated. You also say that the enrollee is not yet able to do much on his own.The Plan denied your request. The Plan says Medicare coverage criteria have not been met for admission to an acute inpatient rehabilitation facility.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 does not require the intensity of services provided at an IRF. Our reviewer found that specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician reviewer also found that the enrollee'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-approveacute IRF admission and services.