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

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee needs to be stronger 
before returning home. The Plan denied your request. The Plan says continued SNF care is not medically 
necessary and the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy 
and occupational therapy in the SNF. The enrollee was at a minimal assist to modified independent level with 
functional mobility, including gait to 300 feet with a rolling walker. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not meet the 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 the continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) 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. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF is the appropriate level of care. The Plan 
denied your request. The Plan says the guidelines for coverage of IRF care have not been 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 in the Medicare rules section. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for failure to thrive. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power wheelchair. 
 
You asked the Plan to pre-approve a Group 1 standard power wheelchair (K0813). You say that you say you 
can barely walk. The Plan denied your request. The Plan says you use a walker inside the home and the power 
wheelchair would only be used outside therefore it is not covered by Medicare or the Plan. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker. The Home Assessment shows the PMD would 
be stored and used outside the home. Although this item may be helpful, neither Medicare nor the Plan cover 
PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power wheelchair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for Ketamine infusions. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 
an out-of-network referral for Ketamine infusions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) and bone replacement graft for 
ridge preservation (D7953). 
 
You asked the Plan to pay for the endosteal implant and bone replacement graft. You say that you would like 
these services to be approved for coverage. The Plan denied your request. The Plan says these services are not 
covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 an 
endosteal implant (D6010) and bone replacement graft for ridge preservation (D7953).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (CPT 99284) provided to the 
enrollee on June 16, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support the evaluation/management level as reported on the claim. 
 
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  is "Emergency department visit for the evaluation and 
management of a patient, which requires these 3 key components: A detailed history; A detailed examination; 
and Medical decision making of moderate complexity." 
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
enrollee presented with flank and right upper quadrant abdominal pain after having been recently worked up 
for the same pain without a diagnosis. A detailed history was documented as well as a physical examination 
showing tenderness in the abdomen. CT abdomen showed non-obstructing calculi at lower pole of left kidney, 
diverticulitis. The labs were within normal limits. The enrollee was given Reglan and symptoms resolved. The 
presentation and workup did not reveal a high-risk situation and was not of moderate complexity based on the 
notes. Therefore, the code, 99284 is not supported. 
 
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 pay for emergency department services (CPT 99284) provided to the enrollee on June 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the HHA or certified nurse assistant providing care in the 
home provided from June 7, 2020, to August 15, 2020. 
 
You asked the Plan to pay for the HHA or certified nurse assistant. You say that you needed these services. The 
Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file does not show that skilled nursing or therapy services were provided under a home health plan of care 
during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
the HHA or certified nurse assistant providing care in the home provided from June 7, 2020, to August 15, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx testing provided on September 4, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx is covered for the conditions 
established in the applicable LCD. 
   
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 the testing. Our reviewer says that the 
requested testing was not medically reasonable and necessary. Our physician reviewer found that this is the 
enrollees first biopsy and the test is not being used to consider for repeat biopsy. Medicare criteria has not 
been met. The requested testing is not medically reasonable and necessary according to coverage criteria 
established in the applicable LCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the ConfirmMDx testing provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
specialist on August 25, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you had your results read to you. 
You say that this should not qualify as an office visit. 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 $45 
copayment for physician/practitioner services/specialty physician.  
 
You have been asked to pay a $45 copayment for an office visit. Additional services, such as reading test 
results, result in a copayment; therefore, the correct copayment has been applied. An office visit falls within the 
physician/practitioner services/specialty physician 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 office visit provided by a participating specialist on August 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for several drug injections (J1453, J2505, 
J9171, J9306, Q5117) provided on October 6, 2020, and October 27, 2020. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you do not understand or 
agree with the costs of the injections. The Plan denied your request. The Plan says the cost-shares were 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% 
coinsurance for Medicare Part B chemotherapy and non-chemotherapy prescription drugs. 
 
You have been asked to pay 20% coinsurance for the drug injections. These injections fall within the Medicare 
Part B prescription drugs 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 several 
drug injections (J1453, J2505, J9171, J9306, Q5117) provided on October 6, 2020, and October 27, 2020.  
 
Your complaint about what you believe are arbitrary and exorbitant costs of your injections 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-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the record does not show that the enrollee requires daily skilled nursing 
or skilled therapy in a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 has a history of back pain. 
The requested Superion spacer is considered experimental/investigational in nature, as more research is needed 
to show safety and efficacy. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this cannot be approved without an updated reassessment of the enrollee's status and 
progress toward treatment goals. 
 
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 additional requested 17 therapy visits are not generally accepted as 
specific and effective therapy for the patients condition beyond what was approved by the health plan. The 
enrollee has had prior therapy of 10/27 recent outpatient visits approved and the records do not demonstrate the 
outcome of this therapy and whether the unique skills of a professional therapist are required to safely and 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
for physical therapy, by or under the supervision of a therapist. The requested services are not part of a 
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to 
establish, design and/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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation (A0425, A0428) 
provided on August 10, 2020. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you were under the 
impression that ambulance services were covered, and you should not be responsible to pay for the services. 
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 $325 
copayment for ambulance services.  
 
You have been asked to pay $256.08 for ambulance transport. The services at issue fall within the ambulance 
services benefit category. Since the Allowed Amount for this service is less than the required copayment of 
$325, you have been asked to pay only $256.08. 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 
ambulance transportation (A0425, A0428) provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair provided on October 4, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the power wheelchair. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this is not a covered service. 
 
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 had network providers 
available who could have provided 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 power wheelchair provided on October 4, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasound of a pregnant uterus (76816). 
 
You asked the Plan to pre-approve an ultrasound of a pregnant uterus. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is only supported if the enrollee is at least 23 week pregnant. 
 
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 an ultrasound of a pregnant uterus. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found an ultrasound was performed on February 2, 2021, and demonstrated that the 
initial subchorionic hemorrhage was no longer identified, but a subtle lucency was noted inferior to the 
gestational sac, likely representing the subchorionic hemorrhage migrating inferiorly. An ultrasound performed 
on February 15, 2021, demonstrated diminishing size of the residual subchorionic hemorrhage. Follow-up 
ultrasonography should be performed as clinically indicated. The available documentation in the case file does 
not indicate the enrollee's current clinical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultrasound of a pregnant uterus have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasound of a pregnant uterus (76816).