Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health 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 the approved visits should be enough to complete goals, teach a home exercise program, 
and establish a safe discharge plan. 
 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have documented skilled therapy needs. The enrollee is mobilizing with stand-by assistance and appears to 
be appropriate for a lower level of care, such as a home exercise program, outpatient therapy, or personal care 
assistance. 
 
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 home health physical therapy services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to have been improving overall but is still somewhat unstable 
(wound infection) and requires short-term additional acute care services that can safely be administered at the 
current facility until more stable and appropriate for a lower level of care. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer may be 
considered when treatment has completed and the enrollee is more stable. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
September 11, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that there were no walk-in clinics open at 
that time. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $100 
copayment for each emergency room visit.  
 
You have been asked to pay a $100 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on September 11, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that records do not show the enrollee has a skilled need, and the services the 
enrollee needs can safely be received at a different 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 care. Our reviewer says that that 
SNF care is medically reasonable and necessary for the enrollee. The enrollee does not have documented 
skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning 
below her baseline. The documentation does not yet establish that the enrollee has reached a new, lower level 
of function. Daily skilled services are required to establish a maintenance program or to prevent deterioration 
of the enrollees condition. Our physician reviewer found that the enrollee's condition meets Medicare criteria 
for SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care 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.
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. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for an admission to an IRF. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient services on December 23, 
2021. 
 
You asked the Plan to waive the copayment for the inpatient admission. You say that you've been charged for 
an overnight stay but did not stay overnight. You say that you went home the same day as your hip surgery, and 
you will not pay the $390 copayment. The Plan denied your request. The Plan says the copayment applied was 
correct because you were admitted to the hospital for your surgery. 
 
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 $390 
copayment for each Medicare-covered inpatient admission.  
 
You have been asked to pay a $390 copayment for inpatient services. The inpatient services fall within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  
  
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient services on 
December 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide hours (18 hours per week). 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says the hours must be reduced. 
 
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.  
 
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 hours. Our reviewer says 
that the requested hours are not medically reasonable or necessary. Our physician reviewer found the 
documentation does not show that additional hours are medically reasonable or necessary to intermittently 
assist in the treatment of an acute illness or injury. 
 
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 additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health aide hours (18 hours per week).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 endosteal implants (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee lost their teeth due to 
periodontal disease. You say that the enrollee needs to replace these teeth with implants in order to restore 
masticatory function. The Plan denied your request. The Plan says implants are not covered services. 
 
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 implants are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 7 endosteal 
implants (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on October 6, 2021. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 
 
 
 
 
 
 
 Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on October 6, 
2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography/computed tomography (PET/CT) 
scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered for adenocarcinoma of the prostate. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found Ga 68 PSMA-11 
with PET scan is indicated for patients with suspected prostate cancer metastasis (when cancer cells spread 
from the place where they first formed to another part of the body) who are potentially curable by surgery or 
radiation therapy. Ga 68 PSMA-11 is also indicated for patients with suspected prostate cancer recurrence 
based on elevated serum prostate-specific antigen (PSA) levels. Ga 68 PSMA-11 is a radioactive diagnostic 
agent that is administered in the form of an intravenous injection. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
positron emission tomography/computed tomography (PET/CT) scan 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), provided on October 12, 2021. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service is denied due to being considered as being a part of the global 
surgical package of minor procedure (0-day) code 67028 which was billed on same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these 
procedures includes payment for the pre-operative visits when furnished by the physician who performs the 
surgery.   
 Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for 
the procedure, unless a significant, separately identifiable service is also performed. Moreover, where the 
decision to perform the minor procedure is typically done immediately before the service, it is considered a 
routine preoperative service and a visit or consultation is not billed in addition to the procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the surgical code 67028 was performed on the 
same date of service by the same physician. Payment for the pre-operative evaluation and management service 
is included in the payment for the surgical service performed on the same day. Of note, the evaluation and 
management service was not billed with a modifier to indicate that it was separate and distinct from the surgery 
service. Therefore, we decided that the Plan does not have to pay for the office visit (99213), provided on 
October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
17, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the labs were ordered by 
your doctor before your physical. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for laboratory services provided on November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from March 30, 
2021, to April 14, 2021, billed with diagnosis related group (DRG) code 853. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 853. You say that you would like 
this claim to be reprocessed for benefits. The Plan denied your request. The Plan says DRG 853 is not 
supported as the diagnosis of Streptococcal sepsis, unspecified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A40.9, defined as 
Streptococcal sepsis, unspecified. 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 inpatient 
hospital services billed with DRG 853. Our reviewer says that the submitted DRG is not supported. Our 
physician reviewer found the medical records did not support the billing of Streptococcal sepsis, unspecified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from March 30, 2021, to April 14, 2021, billed with diagnosis 
related group (DRG) code 853.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urology services provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON urology services. You say that you were not aware that the provider is 
out-of-network and therefore did not obtain authorization. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
 
 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 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 urology services provided on January 3, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) rendered by the out-of-network 
(OON) provider on November 2, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99202) rendered by the out-of-network (OON) provider on  
November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213, 99214) rendered by an out-of-
network (OON) provider on June 29, 2021 and July 14, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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. 
 
You are not a network provider with the Plan. The Plan had network providers available who could have 
provided 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 office visits (99213, 99214) rendered by an out-of-network (OON) provider 
on June 29, 2021 and July 14, 2021.