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

 
We decided that the Plan does not have to pay for inpatient care from 11:56 AM on May 25, 2020, through 
May 26, 2020. 
 
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee was stable as of 11:56 AM on May 25, 2020. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that the 
services at issue were unauthorized post-stabilization care. Our physician reviewer found he documentation 
indicates that as of 11:56 am on May 25, 2020, the enrollee was clearly stable for transfer via ambulance with 
monitoring to a Plan facility. She was admitted for having an elevated Potassium level, chronic obstructive 
pulmonary disease exacerbation and to rule-out COVID-19. The enrollee's Potassium level had improved, her 
oxygen saturation level was 100% on 4 liters oxygen via nasal cannula, and she had ruled out for COVID-19. 
No new orders were written or added to the enrollee's current regimen. The review has determined that the 
treating physician did not document that the patient was not stable for transfer on any dates of service. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care from 11:56 AM on May 25, 2020, through May 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from December 18, 2019 
to April 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from December 18, 2019 to April 16, 2020.  
 
Benefits for these services 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an external electrocardiographic recording 
provided on May 28, 2020. 
 
You asked the Plan to waive the copayment for an external electrocardiographic recording. You say that you 
should not owe anything for diagnostic services. 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 a $40 
copayment for specialist visits.  
 
You received an external electrocardiographic recording provided on May 28, 2020. The external 
electrocardiographic recording was billed as a specialist service. Therefore, you are responsible to pay the 
allowed amount of $27.95, which is less than the $40 copayment.  
 
You have been asked to pay $27.95 for an external electrocardiographic recording. An external 
electrocardiographic recording falls within the physician/practitioner services, including doctor's office visits 
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 external electrocardiographic 
recording provided on May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the battery purchased on May 18, 2020. 
 
You asked the Plan to waive the deductible for the battery. You say that it was cheaper ordering from this 
provider. The Plan denied your request. The Plan says that your deductible was not met when this was 
purchased. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible for out-of-network medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category out-of-
network medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $1,000 deductible for out-of-network medical services. This cost sharing is a contractual obligation that 
had not been met at the time the battery was received on May 18, 2020. Therefore, we decided that the Plan 
does not have to waive the deductible for the battery purchased on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on February 4, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. 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. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 specialist services provided on February 4, 2019 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires additional visits 
for development of a custom seating system The Plan denied your request. The Plan says ongoing OT needs are 
not indicated or necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
The file shows that 4 occupational therapy visits were requested. The Plan has agreed to pre-approve 2 visits. 
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 additional services. Our physician 
reviewer found that the requested additionally therapy is not generally accepted as specific and effective 
therapy for the enrollee's condition. He does not require the unique skills of a professional therapist to safely 
and effectively provide treatment beyond what was already approved by the health plan. The services do not 
need to be performed only by a therapist, or under the supervision of a therapist. The patient does not need the 
additional therapy with  the specialized skill, knowledge and judgment of a qualified therapist  to establish, 
design or deliver a program to maintain the enrollee'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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupational therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 5, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says services are 
available within the network. 
 
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 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 on March 5, 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 lab services provided on April 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that you are not responsible for obtaining prior 
authorization. The Plan denied your request. The Plan says prior authorization is required. 
 
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 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 the lab services provided on April 8, 2020 by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation provided 
on February 11, 2020. 
 
You asked the Plan to pay for the bone replacement graft. You say that you have tried to become in-network 
with the Plan, but are getting the run around. You also say that the provider is in-network at another location, 
and you need this office added as in-network. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's plan. The Plan also says that they have approved payment for the January 29, 2020 
date of service. 
 
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 pay for the bone 
replacement graft for ridge preservation provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 6, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says coverage is limited to one test per specimen. 
 
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 claim provided does not show that the coding and billing guidance has been followed. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 testing provided on May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided from January 5, 2020 to 
February 5, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that the life vest is medically necessary and 
you disagree with the charges. 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 DME and related supplies.  
 
You have been asked to pay the total amount of $1,100 which is less than the 20% coinsurance for DME. DME 
falls within the DME and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for DME provided from January 5, 2020 to February 5, 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. 
 
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 you do not have any complex medical needs requiring medical 
management oversight at least three times weekly and can receive rehabilitation therapy in a less intense 
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. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for swelling and pain in the right 
knee. You were discharged home on October 3, 2020 with home health services. Medical problems are stable. 
There is no documented need for inpatient medical care. There are no complex nursing or rehabilitation needs. 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot walk or use the restroom 
safely on her own. The Plan denied your request. The Plan says the enrollee has no skilled nursing needs, and is 
not able to participate in daily skilled therapy. 
 
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 physician reviewer 
found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There 
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a minimal assist 
level with functional mobility. She required varying assist with activities of daily living. Although there are 
skilled therapy service needs, 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 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-approve 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require the intensity of services and multiple resources available in a rehab 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 physician reviewer found 
that the enrollee's current level of function is at a supervision level for transfers, minimal assistance for 
ambulation using a wheeled walker, and minimal assistance for grooming and toileting. 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. His medical status does not currently require intensive 
physician and nursing oversight only in an IRF. He may benefit from 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve knee surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested service is not supported when an x-ray shows a Kellgren-Lawrence 
grade 2 or greater. 
 
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 the surgery. Our reviewer says that the 
requested knee surgery is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with complaints of progressively worsening left knee pain with associated swelling, 
restricted motion, clicking and locking. Clinical exam findings are consistent with imaging evidence of 
complex medial meniscus tear, mild medial compartment osteoarthritis, and prominent joint effusion. She has 
failed to improve with reasonable conservative treatment. Authorization was requested for left knee 
arthroscopy with meniscectomy, chondroplasty, and synovectomy. Partial approval has been provided for left 
knee arthroscopy with meniscectomy and chondroplasty. Current evidence based medical literature supports 
surgical intervention, inclusive of synovectomy, for mild osteoarthritis in the setting of mechanical symptoms 
and at the time of meniscectomy. Synovectomy is reasonably indicated at the surgeon's discretion upon 
arthroscopic evaluation. Therefore, the request for knee surgery, including CPT code 29875, 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 the surgery have been met. Therefore, we decided that the Plan has to pre-
approve knee surgery for the enrollee.  
 
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.