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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure and was discharged home with home health services. The enrollees medical problems are stable. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says the facet 
joint interventions do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement in the ability to perform 
previously painful movements and ADLs as compared to baseline measurement using the same scale. In 
addition, for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per 
rolling 12 months. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found in this case, the request for 
repeat RFA is not a covered procedure given that the planned bilateral RFA exceeds the frequency limitation 
for RFA for this spinal region for these rolling 12 months. The review has determined that the requested facet 
joint interventions do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 1, 2021, to July 6, 2021.  
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 Patient Driven Payment Model (PDPM) code submitted is inconsistent with what was 
approved on the authorization. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of skilled nursing facility (SNF) services 
provided to the enrollee from July 1, 2021, to July 6, 2021 have been met. The provider has not submitted a 
PDPM on the claim that matches the services that they were authorized for. Therefore, we decided that the Plan 
does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 1, 2021, to 
July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental anesthesia. 
 
You asked the Plan to pre-approve the dental anesthesia. You say that the service is medically necessary. The 
Plan denied your request. The Plan says according to the clinical documentation, it does not show that you 
require the removal of multiple teeth or that you have a medical condition that precludes the use of local 
anesthesia. 
 
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. The Plan covers the dental 
anesthesia when the services are medically necessary and reasonable.  
 
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 dental anesthesia. Our physician 
reviewer found the documentation provided does not meet the criteria for coverage for general anesthesia 
(D9222, D9223 and D9612) for the removal of teeth numbers (#'s): 29 and 30. We looked at this physician's 
review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of 
the dental anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve 
dental anesthesia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are not shown to have a significant decline in function.  Your 
baseline is limited by your poor cardiac status. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
can, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) (76706-26) provided January 13, 2022. 
 
You asked the Plan to pay for the ultrasound screening for AAA. You say that this screening was medically 
necessary. The Plan denied your request. The Plan says this service was billed with an inappropriate diagnosis 
code. 
 The Plan follows Medicare rules. The rules explicitly say that the ultrasound screening for AAA is covered 
when all the criteria in the Medicare Rules section. 
 
The ultrasound screening for AAA, was submitted with diagnosis code Z13.6 -  Encounter for screening for 
cardiovascular disorders. The documentation submitted does not provide documentation to show that the 
enrollee falls in any of the risk categories for coverage of the ultrasound screening for AAA. Therefore, we 
decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) (76706-26) provided January 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for continued physical 
therapy and occupational therapy. 
 You asked the Plan to pre-approve the referral. You say that continuity of care is needed with this provider. 
The Plan denied your request. The Plan says this care is available within network and no network exception is 
medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 referral. Our reviewer says that the 
requested services are not medically necessary. Our physician reviewer found the continuation of care with 
OON provider specifically, 23 occupational therapy visits and 23 physical therapy visits is not medically 
necessary per 42 CFR Section 422.112 as the requested services are available in network. One visit has been 
approved to facilitate transition 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 the referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an out-of-network referral for continued physical therapy and occupational therapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the breast, unilateral, limited (76642) 
provided on October 14, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that this service is supported as billed. The Plan denied 
your request. The Plan says this procedure is billed inconsistently with the diagnoses provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 76642-LT is not consistent with the diagnoses billed. Specifically, this service is billed 
as being performed on the left side, but the diagnoses indicated with this service are mastodynia (N64.4) and 
diffuse cystic mastopathy of right breast (N60.11). Based on this information, we decided that Medicare rules 
for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultrasound of the breast, unilateral, limited (76642) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 1, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 1, 2021 have been met. The Plan has not received the required clinical records to support the 
medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does not 
have to pay for an epidural injection provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient clinic visits and wound care 
provided from February 8, 2021, through May 17, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient clinic visits and wound care. You say that you 
were billed and paid for services that did not occur. You say that you were charged for debridement of your 
wound and that did not occur on these dates. The Plan denied your request. The Plan says you have been 
charged the correct coinsurance 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 25% 
coinsurance for each Medicare-covered outpatient surgical service, observation service or ambulatory surgical 
center service up to $1200 annual maximum combined out of pocket cost.  
 
You have been asked to pay a total of $212.68 for the outpatient clinic visits and wound care.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
February 8, 2021 Clinic Visit $108.72 25% $27.18 
February 22, 2021 Wound Care $316.66 25% $79.16 
May 3, 2021 Clinic Visit $108.72 25% $27.18 
May 17, 2021 Wound Care $316.66 25% $79.16 
TOTAL:    $212.68 
 
The outpatient clinic visits and wound care fall within the Outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers 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 the outpatient clinic visits and wound care provided from February 8, 2021, 
through May 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the magnetic resonance imaging of the abdomen; without contrast 
material(s), followed by with contrast material(s) and further sequences (74183) and the gadoterate meglumine 
injection (A9575) rendered by the out-of-network (OON) provider on November 9, 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 that 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 enrollees may receive their care from either a network provider or an out-of-network provider. 
The Plan covers services from an out-of-network provider as long as the services are covered benefits and are 
medically necessary. You dont need to get a referral or prior authorization when you get care from out-of-
network providers.  
 
The provider in this case is not a network provider with the Plan. However, the Plan contract states that as a 
member of the Plan, you may receive your care from either a network provider or an out-of-network provider. 
Additionally, you do not need to get a referral or prior authorization when you get care from out-of-network 
providers. Therefore, we decided that the Plan has to pay for the magnetic resonance imaging of the abdomen; 
without contrast material(s), followed by with contrast material(s) and further sequences (74183) and the 
gadoterate meglumine injection (A9575) rendered by the out-of-network (OON) provider on November 9, 
2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for epidural injection provided on January 13, 
2022. 
 
You asked the Plan to waive the copayment for epidural injection. You say that you did not know you had a 
copayment for this visit. The Plan denied your request. The Plan says copayment is correct. 
 
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 $50 
copayment for outpatient procedures/surgery at an ambulatory surgical center.  
 
You have been asked to pay $50 copayment for epidural injection. The epidural injection falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 epidural injection provided 
on January 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on November 24, 2021. 
 
You asked the Plan to waive the copayment for CT scan. You say that you believe you have a $0 copayment, 
so you should not have to pay this bill. The Plan denied your request. The Plan says copayment is correct. 
 
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 $160 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a fee-standing facility (such as a radiology center or medical clinic 
 
  You have been asked to pay $121.97, which is less than the standard $160 copayment for CT scan. The CT 
scan falls 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 CT scan provided on November 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 8, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the ultrasound should be covered 
like all your other tests. 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 $95 
copayment for diagnostic procedures and tests performed at an outpatient hospital setting.  
 
You have been asked to pay $95 for the ultrasound, which was performed at Orlando Regional Medical Center, 
an outpatient hospital setting. An ultrasound falls 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 the 
ultrasound provided on January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection, of diagnostic or therapeutic substance(s) (eg, 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle 
or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided November 
8, 2021. 
 
You asked the Plan to pay for the injection services. You say that the procedure you are billing for is 
subarachnoid injection of opioid medications. You are appealing the Plan's decision to  deny payment. The 
Plan denied your request. The Plan says the Plan has not received the required clinical records to support the 
medical necessity of the service.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the injection, of diagnostic or 
therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic 
substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic 
(62320) provided November 8, 2021. have been met. the records provided are undated and unsigned by the 
provider. Therefore, we decided that the Plan does not have to pay for the injection, of diagnostic or therapeutic 
substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) 
provided November 8, 2021.