Persius/hicric huggingface dataset:
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 LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
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 patient is a 66-year-old male who was admitted to the hospital with 
congestive heart failure in the setting of ischemic dilated cardiomyopathy, atrial fibrillation, chronic kidney 
disease, hypertension, and coronary artery disease. He was treated with diuresis, antibiotics, and milrinone drip. 
He was deemed not a candidate for mechanical ventilation or heart transplantation. Recent notes describe the 
patient as tolerating room air and near his baseline.  
 
 The patient appears to be improving to baseline home needs and will not undergo an invasive 
treatment/procedure and should only require short-term additional acute care hospital services that can safely 
be administered at the current facility until appropriate for a lower level of care. The patient 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 patient requires that are not already available and covered at the current facility. In conclusion, transfer 
to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of 
care may be considered when treatment has completed. 
 
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 allergy specialist office visit provided on 
May 18, 2021. 
 
You asked the Plan to waive the copayment for an allergy specialist office visit. You say that you waited in two 
waiting rooms and were told they could not give you the serum. You also say that you never saw a doctor, or 
had vitals taken, and you did not get anything else done. 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 an in-network specialist office visit.  
 
 The medical records show you had a specialist office visit on May 18, 2021. You have been asked to pay a $10 
copayment for an allergy specialist office visit. An allergy specialist office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 allergy specialist office visit provided on May 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from March 19, 
2022 onward. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you were admitted to the hospital on 
March 12, 2022. It is not expected that you will improve in a reasonable period of time beyond the date in 
question, as you are complaint with treatment and are not having suicidal or homicidal ideation. You have no 
auditory or visual hallucinations. You are showing no acute threats to your safety. It does not appear that active 
treatment is taking place beyond the date in question. Continued inpatient services are not needed to improve 
your condition or for the purpose of diagnosis. The services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services from March 19, 2022 onward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry specialist office visit provided 
on October 12, 2021. 
 
You asked the Plan to waive the copayment for a podiatry specialist office visit. You say that the provider was 
only in the room for about four minutes. You also say that there are things on the bill that never happened. 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 $40 
copayment for a specialist office visit.  
 You have been asked to pay a $40 copayment for a podiatry specialist office visit. A podiatry specialist office 
visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a podiatry specialist office visit provided on October 12, 
2021.  
 
Your complaint about the amount of time the provider was in the room is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health physical therapy visits. 
 
You asked the Plan to pre-approve 7 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 7 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not have 
documented skilled therapy needs. You are functioning at a level commiserate with a lower level of care. As 
such, the requested, ongoing, home health physical therapy services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 7 home health physical therapy visits.
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 enrollee needs aggressive wound 
management, 24-hour respirator support, 24-hour nurse observation and physical and occupational therapy. The 
representative states the enrollee's needs cannot be met at a lower level of care. The Plan denied your request. 
The Plan says denied authorization because LTACH is not medically necessary and the enrollee's needs can be 
meet at a lower level of care, such as a skilled nursing facility (SNF). 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says these services have not been billed with the 
appropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on February 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Xiidra drops. 
 
You asked the Plan to pre-approve the Xiidra drops. You say that you would like reconsideration because the 
requested Xiidra drops are medically necessary. The Plan denied your request. The Plan says this is not covered 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Xiidra drops.  
 
Benefits for the Xiidra drops may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for hospital services provided from October 29, 2021, to 
November 1, 2021. 
 
You asked the Plan to cover your hospital services as an inpatient stay. You say that the request for an inpatient 
stay was not approved. The Plan denied your request. The Plan says that you have been charged the correct cost 
sharing amount. The Plan also says that as a result of the inpatient hospital authorization being denied, you 
remained in outpatient status. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The Plan 
contract says that enrollees must pay a $90 for an in-network emergency room visit. The Plan contract also says 
that you do not pay the emergency room visit cost share if you are admitted to the hospital. Your contract with 
the Plan also says that enrollees must pay a $0 copayment for in-network outpatient observation.  
 
The Plan confirmed you were admitted to the hospital as an outpatient. The Plan says you must pay a $90 
copayment for hospital services. Based on the Plan contract, however, you cannot be asked to pay more than a 
$0 copayment for hospital services. Therefore, we decided that the Plan has to waive the copayment for 
hospital services provided from October 29, 2021, to November 1, 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: Favorable

 
We decided that the Plan has to pay for the echocardiography (93308), emergency department (ED) visit 
(99285) and cardiopulmonary resuscitation (92950) provided on March 1, 2021. 
 
You asked the Plan to pay for the emergency services. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says that this service was not billed correctly and is not 
a covered service as the enrollee was deceased at the time of services. 
 
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. Specifically, the time that these specific services were provided is not noted in 
the record. There is no evidence in this case that these services were provided after the enrollee was 
pronounced dead. Therefore, we decided that the Plan has to pay for the echocardiography (93308), emergency 
department (ED) visit (99285) and cardiopulmonary resuscitation (92950) provided on March 1, 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: 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 is medically stable enough to complete 
inpatient rehabilitation and is willing and able to complete three hours of therapy a day. The Plan denied your 
request. The Plan says authorization denied because the IRF admission is not medically necessary and the 
enrollee's needs can be met at a lower level of care, such as a skilled nursing facility (SNF) or outpatient setting 
or home health 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 the enrollee's medical problems are stable and 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 enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis; bilateral (CPT code 
77062) provided on October 4, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 

We find that CPT code 77062 is not supported in the medical record. CPT code 77062 has a status code "I" Not 
valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. 
Based on this information, we decided that Medicare rules for coverage of the service have not been met. 
Therefore, we decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis; bilateral 
(CPT code 77062) provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) screening testing 
coded as 81206, 81292, 81301 provided April 29, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that the Tempus Gene Panel will play an 
important role in establishing specific somatic tumor and germline mutations which will guide appropriate medical management of the enrollee. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 
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, we find that CPT code 81206, 81292, 81301 is not supported in the medical record. Specifically, to 
report a CGP, service providers should use 1-unit only of CPT code 81479 (used for the entire bundled multi-
test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative 
field for the test; not unbundled to separate codes, or other unlisted code. Medicare says do not list unbundled 
separate codes 7 or another unlisted code on the claim. Based on this information, we decided that Medicare 
rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not 
have to pay for comprehensive genomic profile (CGP) screening testing coded as 81206, 81292, 81301 
provided April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 7, 8, 9, and 10. 
 
You asked the Plan to pre-approve the crowns. You say that you would like to fix your two front teeth and your 
dentist advised that crowns can be placed to cover the damaged teeth. The Plan denied your request. The Plan 
says tooth #'s 7, 8, 9, and 10 do not qualify for crown coverage due to the documented nature of wear on the 
teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns 
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 crowns. Our reviewer says that 
crowns for tooth #'s 7, 8, 9, and 10 do not meet the criteria for coverage. Our physician reviewer found the 
explanation of coverage specifically states that crown restorations are not a covered treatment for incisal wear 
or attrition. Our reviewer found that the documentation does not indicate significant coronal breakdown due to 
caries or fracture of tooth #'s 7, 8, 9, and 10. Our physician reviewer also found that there does appear to be 
incisal wear due to attrition which is not a criterion for coverage for a crown restoration. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2740) for tooth #'s 7, 8, 9, and 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided March 
12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tooth extractions. You say that you would not have gone to this provider if 
you knew the services would not be paid. The Plan denied your request. The Plan says the extractions are not 
covered because they were provided OON. 
 
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 tooth 
extractions when the services are rendered by a network provider. 
 
We looked at the file and Medicare rules. In this case the tooth extractions were performed by an OON provider. You are responsible for 100% of the cost of services provided OON. Therefore, we decided that the 
Plan does not have to pay for the extractions, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided March 12, 2021, by an out-
of-network (OON) provider.