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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you live alone and cannot be discharged. The 
Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the submitted records show that you 
were admitted to the hospital with a gastrointestinal (GI) bleed. You were treated with oral medications and 
had stable vital signs. You have no skilled nursing or skilled therapy needs. You do not require these services 
on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the 
SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous infusion, hydration; each additional hour (CPT 
Code 96361) provided on March 16, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the fluid used to administer the drug(s) is incidental hydration and is not separately 
payable. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Physician work related to 
hydration, injection, and infusion services involves the affirmation of the treatment plan and the supervision 
(pursuant to incident to requirements) of non-physician clinical staff. A therapeutic, prophylactic, or diagnostic 
IV infusion or injection, other than hydration, is for the administration of substances/drugs. The fluid used to 
administer the drug (s) is incidental hydration and is not separately payable. If performed to facilitate the 
infusion or injection or hydration, the following services and items are included and are not separately billable: 
1. Use of local anesthesia; 2. IV start; 3. Access to indwelling IV, subcutaneous catheter or port; 4. Flush at 
conclusion of infusion; and 5. Standard tubing, syringes and supplies. Payment for the above is included in the 
payment for the chemotherapy administration or non-chemotherapy injection and infusion service. Therefore, 
we decided that the Plan does not have to pay for intravenous infusion, hydration; each additional hour (CPT 
Code 96361) provided on March 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for vasectomy, unilateral or bilateral (separate procedure), 
including postoperative semen examination(s) (CPT Code 55250) provided on March 6, 2020. 
 
You asked the Plan to pay for the services. You say that your provider told you that your insurance would 
cover the vasectomy. You state you had the vasectomy done because getting a vasectomy seemed to be the best 
form of birth control that would work for both of you. The Plan denied your request. The Plan says they do not 
cover a vasectomy. The Plan states they called the doctor's office and were told that the office would not have 
told you that your insurance plan would pay for this service. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Elective hysterectomy, tubal 
ligation, and vasectomy, if the primary indication for these procedures is sterilization is not covered. Therefore, 
we decided that the Plan does not have to pay for vasectomy, unilateral or bilateral (separate procedure), 
including postoperative semen examination(s) (CPT Code 55250) provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient therapy services to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient therapy services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent 
nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network providers available 
to you that can provide the care and treatment you are requesting. 
 
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 outpatient therapy services to be provided by an out of network (OON) provider.
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 are not medically stable because you have worsening pneumonia 
with infiltrates. 
 
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. You 
are generally medically stable with debility from respiratory illness, and continued confusion and low activity 
tolerance with no evidence of medical or nursing needs for an IRF and your current functional status does not 
require IRF level of therapies. There is no evidence of medical issues that require monitoring by an inpatient 
rehab physician three times a week. You will not be able to tolerate IRF intensity of therapies. The 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an 
interdisciplinary approach to rehab care. At min assistance for all mobility, you do not need IRF level of 
therapies and he has no medical complexity or tolerance. Your rehab needs can be safely and effectively met in 
an alternate, less intense setting such as in an SNF. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided on 
February 13, 2019. 
 
You asked the Plan to pay for the service. You say that it takes a half hour to set up the heart lung machine. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Medicare does not pay any provider 
or supplier other than the hospital for services furnished to the beneficiary while an inpatient in hospital and 
this takes precedence over the claim system denial. These services and CPT codes are statutorily excluded by 
Medicare. The facility must furnish all necessary covered services to the beneficiary either directly or under 
arrangements made between the facility and outside vendors. The enrollee received the services in the facility 
during inpatient hospitalization, and payment for this service would be included in the part-A DRG payment to 
the facility. Payment for this service is the responsibility of the facility to any vendor. We find the Medicare 
rule for payment of this February 13, 2019 claim has not been met. Therefore, we decided that the Plan does 
not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG 
and/or pressure monitoring); each hour (CPT Code 99190) provided on February 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new patient consult and dental extraction with an oral 
surgeon. 
 
You asked the Plan to pre-approve the new patient consult and dental extraction with an oral surgeon. You say 
that you have a broken tooth that needs immediate attention. You say that you cannot eat properly. You say that 
the extraction is a very expensive procedure. The Plan denied your request. The Plan says the services being 
requested are not a covered benefit. 
 
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 dental benefit is limited to services 
performed by a participating general dentist. You are requested services from an non-participating oral 
surgeon. Therefore, we decided that the Plan does not have to pre-approve a new patient consult and dental 
extraction with an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
admission to a SNF. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute 
care on 9/30/20 for the evaluation of confusion and right shoulder pain, x-rays of the shoulder were negative 
for fracture. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital 
signs. She was alert with confusion. Regarding rehabilitation services, the enrollee received physical therapy in 
the acute hospital. The enrollee was at a contact guard assist level with functional mobility including gait to 
100 feet.   
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic care provided from May 5, 2020, through May 
13, 2020, by a non-participating provider. 
 
You asked the Plan to pay for chiropractic care. You say that the provider did not have the type of technology 
for a high risk surgery. The Plan denied your request. The Plan says there was not an attempted or approved 
prior authorization on file to cover the chiropractic care with a non-participating 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. 
 
There is chiropractic care with in-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. 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 
chiropractic care provided from May 5, 2020, through May 13, 2020, by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 24, 2018. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the claim was not received within 12 months or 1 calendar year from the date when the 
services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until March 9, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on November 24, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is not completely mobile or ready 
to go home. The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on August 22, 2020 with sepsis and diabetic ulcers of bilateral feet. She had stable vital signs and wound care 
three times per week. She received physical therapy in the hospital and needs assistance with functional 
mobility, including gait to 40 feet with a rolling walker. She has no skilled nursing needs. She has skilled 
therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not 
require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 home health occupation therapy (OT) visits. 
 
You asked the Plan to pre-approve 10 home health OT visits. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 10 home health OT visits. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you do not have documented 
skilled OT needs. Your care needs, as a practical matter, can be provided 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 10 home health OT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 home health occupation therapy (OT) visits.
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different 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. Our 
physician reviewer found based on the medical records provided 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. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous spacer.
You asked the Plan to pre-approve a Vertiflex interspinous spacer. The Plan denied your request. The Plan says
this is not medically necessary.
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 Vertiflex interspinous spacer. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that there is no spinal instability. The device is experimental. More research is
needed to show safety and efficacy.
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 Vertiflex interspinous spacer have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Vertiflex interspinous spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22867, 22868). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the device is experimental. More research is needed to show safety and 
efficacy. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22867, 22868).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on April 8, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthosis have not been met. Healthcare Common Procedure 
Coding System (HCPCS) code L0650 CG (1 Unit) remains not supported. The documentation submitted did 
not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery on the 
billed date of service. Therefore, the billed supply code cannot be verified.  It is noted that multiple attempts 
were made to contact the provider for additional information. Therefore, we decided that the Plan does not have 
to pay for the lumbar-sacral orthosis (L0650) provided on April 8, 2020.