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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from LTACH 
admission with the need of intensive physical therapy and occupational therapy. The Plan denied your request. 
The Plan says the enrollee is unstable for transfer. The enrollee's care needs can be safely managed in the 
current acute care setting until they are deemed medically stable for discharge to a lower-level setting. 
 
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 that the enrollee appears to be improving but still somewhat unstable and should only 
require short-term additional acute care services that can be safely administered at the current facility until 
more stable and appropriate for transfer to a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 
  
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as the enrollee is not currently stable and as 
it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on November 2, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The codes at issue were billed with a -91 modifier. The records provided do 
not indicate testing was performed more than once on the same day for the enrollee. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab testing services provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 19, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on April 19, 2022, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission and services is medically 
necessary. The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare 
guidelines. The enrollee does not have complex rehabilitation, medical, or nursing needs. The enrollee does not 
need to be assessed medically and functionally or need supervision face-to-face by a rehabilitation doctor at 
least 3 days per week. The enrollee does not need 3 hours of therapy per day or 15 hours per week. The 
enrollee's needs can be met at an alternate 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 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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least 3 hours a day 
and 5 days a week, or 15 hours over 7 consecutive days. The enrollee is currently requiring moderate assistance 
with transfers and ambulating 80 feet with a walker with maximum assistance. The enrollee requires maximum 
assistance with dressing and is dependent for toileting. The enrollee was evaluated by speech therapy and can 
tolerate regular diet with thin liquids. The enrollee has had a functional decline from his baseline level of 
function, and they would benefit from therapy, but it is unclear if they can tolerate the intensity of therapy 
services on acute inpatient rehabilitation and requires this level of intensity. Therefore, the acute inpatient 
rehabilitation admission is not 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0998 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code A0998. You say that you do not feel this is a valid cause to 
require you to be charged for this error on the safe side was warranted. You also say that you feel you should 
not be responsible for this bill. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A0998 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A0998 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A0998 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A0998 billed for date of service May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the enrollee has medical conditions that puts 
them at higher risk when put under anesthesia. You say that the claim should be reviewed and reprocessed for 
additional payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the thorax, 
abdomen and pelvis (71270, 71260, 74176, 71250). 
 
You asked the Plan to pre-approve CT scans. You say that these imaging services are medically necessary as 
the enrollee is showing concerning symptoms which warrant further investigation. The Plan denied your 
request. The Plan says the enrollee has had a negative electrocardiogram, echo and nuclear cardiac study, no 
gastrointestinal scope or ultrasound and no abnormal labs. There is no indication which would determine that 
the requested CT scans are medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scans. Our reviewer says that the 
criteria for coverage of the requested imaging services are not met. Our physician reviewer found the enrollee 
has a history of chest and epigastric and left lower quadrant pain. The trans-esophageal echo and nuclear 
medicine stress test were normal. No results of a plain chest x-ray were provided and there is no clinical 
evidence of pulmonary embolism. The request for CT of the chest absent any other clinical indications 
including abnormal chest x-ray is not reasonable especially if they are to be done without contrast material as 
requested. Such a study would not evaluate for vascular causes of chest pain. There is no ultrasound of the 
abdomen or pelvis within the enclosed records, no endoscopic report and no colonoscopy records for this 
enrollee with epigastric pain and left lower quadrant pain with normal blood count. Without this information, the medical necessity of CT of the abdomen and pelvis without contrast is not established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scans of the thorax, abdomen and pelvis (71270, 71260, 74176, 
71250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve an endosteal implant. You say that the implant is needed due to an injury. 
The Plan denied your request. The Plan says implants are not covered under your dental or medical benefits. 
 
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 pre-approve 
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you believe IRF admission and services is your best 
opportunity to get better. The Plan denied your request. The Plan says the records show that it is not reasonable 
to expect that the enrollee will be able to safely participate in, or fully benefit from, the intensity of services of 
an IRF. It is not reasonable to expect that the enrollee would be able to take part in 3 hours of therapy 5 days a 
week or 15 hours of therapy a week. The services the enrollee needs can be provided safely in other settings 
like a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 that it is not reasonable to propose intensive rehabilitation for a person who is non 
weight bearing in both legs. The enrollee is very limited in the activities they can do at present. Uncomplicated 
fracture of lower extremities does not require frequent physiatry oversight. Admission to an IRF is not 
medically reasonable or necessary. The enrollee cannot begin significant rehabilitation until their limbs can 
weight bear. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services provided on April 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for diagnostic services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. The services could have been provided by an in-network 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. 
 
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 diagnostic services provided on April 3, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture (D5213), an alveoloplasty with 
extractions (D7310), and an extraction (D7210) for tooth #5. 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain, and you need these dental 
services completed. The Plan denied your request. The Plan says that based on the records and x-rays that the 
dentist sent to them the dental services are denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The denial reason given was out of medical necessity. The Plan did not submit 
any medical documentation or x-rays supporting the denial out of medical necessity. Therefore, we decided that 
the Plan has to pre-approve an upper partial denture (D5213), an alveoloplasty with extractions (D7310), and 
an extraction (D7210) for tooth #5.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings-three radiographic images (D0273), panoramic 
radiographic image (D0330), and comprehensive oral evaluation (D0150) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should only have to pay $45 and the plan 
should pay $211. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewings-three radiographic images (D0273), panoramic radiographic image (D0330), and 
comprehensive oral evaluation (D0150) provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator to be used for the treatment 
of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have COPD with recent 
exacerbations. There is mild increase in the PaCO2, although there is no ABG done as an outpatient while 
stable. If you do have chronic CO2 retention, you may benefit from BiPAP with AVAPS during sleep. 
Medicare does not cover a home ventilator when used as BiPAP. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an onabotulinumtoxina injection provided 
on June 13, 2022. 
 
You asked the Plan to waive the copayment for an onabotulinumtoxina injection. You say that you have never 
been charged a coinsurance for Part B drugs before, therefore you should not be responsible for this. The Plan 
denied your request. The Plan says the cost share 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 20% 
coinsurance for all other Part B drugs (not allergy serum, nebulized medications, or chemotherapy drugs) 
provided at a PCP's office, a specialist's office, in the home, or in an outpatient hospital setting.  
 
You have been asked to pay $205.16 for an onabotulinumtoxina injection. An onabotulinumtoxina injection 
falls 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 copayment for an onabotulinumtoxina injection. provided on 
June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation for therapy 
and with rehabilitation the enrollee will gain full function to go home with. The Plan denied your request. The 
Plan says the records show that it is not reasonable to expect that the enrollee will be able to safely participate 
in, or fully benefit from, the intensity of services of an IRF. It is not reasonable to expect that the enrollee 
would be able to take part in 3 hours of therapy 5 days a week or 15 hours of therapy a week. The services the 
enrollee needs can be provided safely in other settings like a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
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 that 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 septic shock, bacteremia, intraparenchymal hemorrhage. 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 this 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 IRF admission and services.