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. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is needed to regain maximum function. The 
Plan denied your request. The Plan says you do not meet criteria for an IRF admission. 
 
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. 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 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 requires additional short-term acute care services that can be safely 
administered at the current facility. Once the enrollee is stable, the enrollee can be transferred to a lower level 
of care. The enrollee does not require services at the LTACH that are not already available at the current 
facility. 
 
 
 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 pre-approve an out-of-network neurology consultation.  
 
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested 
provider. The Plan denied your request. The Plan says the requested provider is not in network. 
 
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 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 neurology 
consultation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 non-surgical management of hip and coccyx after a fall. 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 documentation does support a need for physical and/or occupational therapy, there is no 
documented need for an intensive, multi-disciplinary rehabilitation program. 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 acute IRF admission and 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 the enrollee currently meets IRF admission criteria 
under CMS guidelines. The Plan denied your request. The Plan says the enrollee does not meet all the required 
Medicare criteria for 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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5225). 
 
You asked the Plan to pre-approve the upper partial denture (D5225). You say that cancer treatment caused you 
to lose your top teeth and you need the top denture. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
upper partial denture (D5225).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on May 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 the drug testing services (G0483) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six surgical extractions (D7210 x6) and two removals of 
residual tooth roots (D7250 x2) to be rendered at an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve the surgical extractions and removals of residual tooth roots. You say that 
your infected teeth are causing you medical issues. The Plan denied your request. The Plan says the teeth 
removal would be covered if it was to prepare the jaw for radiation treatment. The Plan also says that your 
doctor's notes do not show that you need radiation treatment.  
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. You have requested that these services be rendered in an out-of-
network facility. Services provided OON are not covered under your plan. The contract says that dental 
services and any related fees performed in a treatment facility other than the contracted providers office are 
not covered. Therefore, we decided that the Plan does not have to pre-approve six surgical extractions (D7210 
x6) and two removals of residual tooth roots (D7250 x2) to be rendered at an out-of-network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
March 16, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 out of network physician services provided to the 
enrollee on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric sleeve surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that bariatric surgery is covered for Medicare beneficiaries 
who have a BMI of 35 of more. 
 
The file shows that your BMI is less than the requirement of 35 or more. Based on this information, we decided 
that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gastric sleeve surgery.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of SNF services provided from March 14, 2021, 
through April 12, 2021. 
 You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
continuation of SNF services was 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 pay for continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the enrollee required skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and 
effectively provide medically necessary and reasonable treatment. This enrollee did not require skilled therapy 
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely 
and effectively provide medically necessary and reasonable treatment. Daily skilled services were not required. 
As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing 
facility setting. Services in the nursing facility appear custodial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of SNF services provided from March 14, 2021, through  
April 12, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the gastrointestinal services you received on May 28, 
2021. 
 
You asked the Plan to waive the cost sharing for the gastrointestinal services. You say that there appears to be a 
duplicate billing on this claim. The Plan denied your request. The Plan says that this coinsurance was charged 
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 does not say in clear and accurate 
terms how much you should expect to pay for gastrointestinal services.   
 
We looked at your contract with the Plan and the case file they submitted. The Plan has the burden of showing 
that their assessment of coinsurance is correct. The Plan provided very little information in this case file.  There 
was no copy of the actual claim provided, so we can only base our decision on the limited documentation that 
the Plan supplied. The Explanation of Benefits states that coinsurance was applied to three specific line items, 
all of which just had generic explanations of gastrointestinal services, billing code 0750. There is no 
explanation as to the specific services received. There is no explanation as to why multiple charges of $3486.29 
were charged. The Plan failed to address your argument at all regarding the multiple line items with the same 
coinsurance charged. While the cost sharing may be appropriate, we have no way of confirming that with the 
scant information provided to us by the Plan. We find that the Plan did not meet its burden in proving that its 
assessment of coinsurance was correct in this case. Therefore, we decided that the Plan has to waive the cost 
sharing for the gastrointestinal services you received on May 28, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep test (G0399). 
 
You asked the Plan to pre-approve the home sleep test. You say that the enrollee's Continuous Positive Airway 
Pressure (CPAP) machine is no longer in working order and cannot be replaced due to the company no longer 
making those machines. You also say that it has been over 2 years since a sleep study was done, and a new 
sleep study needs to be done in order for the enrollee to receive a new CPAP machine. The Plan denied your 
request. The Plan says the requested service does not meet coverage indication criteria because the enrollee was 
already diagnosed with Obstructive Sleep Apnea (OSA). The Plan also says that the enrollee's OSA symptoms 
were resolved with positive airway pressure (PAP) treatment and only recurred when using a malfunctioning 
CPAP machine. 
 
The Plan must follow Medicare rules. Medicare rules say that more than one Home Sleep Test (HST) to 
establish the diagnosis of Obstructive Sleep Apnea (OSA) would not be expected. If more than one HST 
session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the 
additional tests will be required. 
 
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 home sleep test. Our reviewer says 
that this request for a sleep study is considered not medically necessary at this time. Our physician reviewer 
found there is no clear reason for the enrollee to undergo a repeat sleep study. Our reviewer also found that a 
solution would be to continue a new CPAP machine using the same settings as the previous model and then reassess symptoms before considering repeat testing. 
 
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 home sleep test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home sleep test (G0399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the familial hypocalciuric hypercalcemia (FHH) gene 
panel for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that the test has important implications as it could help 
determine if the enrollee's hypercalcemia is from primary hyperparathyroidism or from familial hypocalciuric 
hypercalcemia. The Plan denied your request. The Plan says this test is unlikely to impact therapeutic decision-
making in the enrollee. 
 
The Plan must follow Medicare rules. The rules say that the FHH test is unlikely to impact therapeutic 
decision-making, directly impact treatment, outcome and/or clinical management in the care of the beneficiary. 
 
As this test is unlikely to impact the medical management of this enrollee, it will be considered not reasonable 
or necessary. 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 pre-approve the familial hypocalciuric 
hypercalcemia (FHH) gene panel for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that you are behind in your 
physical therapy and are requesting an expedited appeal. The Plan denied your request. The Plan says 
additional visits are not medically necessary. 
  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 8 additional physical therapy visits. 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 that you had prior therapy, were already approved for 
4 additional therapy sessions, and can transition to a home exercise program. Our reviewer says that the unique 
skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.