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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and the IRF 
care can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 
 
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 a dental surgery procedure (41899). 
 
You asked the Plan to pre-approve the dental services. You say that the service requested is medically 
necessary. The Plan denied your request. The Plan says the service at issue 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 a 
dental surgery procedure (41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant (D6010 x2). 
 
You asked the Plan to pre-approve surgical placement of implant. You say that the requested services are 
medically necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 (D6010 x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine services provided on 
April 7, 2022. 
 
You asked the Plan to waive the copayment for nuclear medicine services. You say that you weren't aware of 
how much the charge would be. The Plan denied your request. The Plan says the copayment applied 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 $485 
copayment for nuclear medicine services in an outpatient hospital.  
 
You have been asked to pay $485 copayment for nuclear medicine services. Nuclear medicine services fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for nuclear medicine services provided on April 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
March 11, 2022, to March 25, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you thought this was fully 
covered. The Plan denied your request. The Plan says the copayment applied 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 $295 
copayment per day for days 1through 6 for each Medicare-covered admission. No copayment for additional 
days per stay.  
 
 
 
 You have been asked to pay $1,770 ($295 x 6 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for inpatient hospital stay provided from March 11, 2022, to March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on April 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the enrollee has an approved admission in a 
nursing/rehabilitation facility. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 wound care services provided on April 15, 2022, 
by an out-of-network (OON) provider.
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 physician submitted a referral to a skilled
nursing facility for daily physical and occupational therapy. You also say that the enrollee has dementia, so it is
more important for her to be supervised by a skilled physical therapist daily, in a facility that requires her to
participate in a daily routine to manager her rehabilitation, observe, assess, and evaluate her care plan, as she is
not capable of that on her own. The Plan denied your request. The Plan says the enrollee did not appear to meet
Medicare criteria for this service.
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 the
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there are no identifiable skilled nursing service needs. Our physician reviewer also
found that this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis
in a skilled nursing facility setting.
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided from January 11, 
2022, to April 6, 2022. 
 
You asked the Plan to waive the copayment for office visits . You say that these should be covered. The Plan 
denied your request. The Plan says the cost share applied 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 $30 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). 
.  
 
 You have been asked to pay $194.85 ($30 x 6 visits) ($14.85 for one visit) copayment for office visits. Office 
visits 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 office visits provided from January 11, 2022, to April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
monitor is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing
results. Based on this information, we decided that Medicare rules for coverage of the requested services have
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that your husband has seen this physician and 
would like to see them for a second opinion. The Plan denied your request. The Plan says the services have 
been requested out-of-network and there are in-network providers available. 
 
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 requested 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 outpatient visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 1, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were told you would only have 
a $10 copayment. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for Medicare covered Part B chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay $200.37 which is 20% of the allowed amount for an injection. The allowed amount 
is $1,001.86 (20% x $1,001.86= $200.37). Injections fall 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 coinsurance for an injection provided on April 1, 2022.
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 medically necessary for this enrollee. The 
Plan denied your request. The Plan says the criteria for admission to an IRF are not met in this case. The 
enrollee's necessary care can be provided in a less intensive setting. 
 
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 enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 25, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this was supposed to be covered. 
The Plan denied your request. The Plan says the copayment applied 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 $110 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
 
 You have been asked to pay $110 copayment for an ultrasound. Ultrasounds fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an ultrasound provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), a panoramic 
x-ray (D0330), and resin-based composite fillings (D2335). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a 
comprehensive oral evaluation (D0150), a panoramic x-ray (D0330), and resin-based composite fillings 
(D2335).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240). 
 
You asked the Plan to pre-approve a pontic. You say that this service is medically necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted during this authorization review. Therefore, 
we decided that the Plan does not have to pre-approve a pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4261). 
 
You asked the Plan to pre-approve the dental service. You say that you have a deep pocket that requires a bone 
transplant to fill the pocket. You also say that if you do not receive the surgery, you risk losing the tooth. The 
Plan denied your request. The Plan says osseous surgery is not listed as 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 osseous surgery is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4261).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care office visit provided on 
February 25, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were advised there would be 
no copay 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 $65 
copayment for urgently needed services visit.  
 
You have been asked to pay a $65 copayment for the office visit. The office visit falls within the Urgently 
Needed Services 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 urgent care office 
visit provided on February 25, 2022.
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 you need intensive rehabilitation services and cannot 
recover in a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an 
IRF are not met. The care you need can be provided in a less intensive setting. 
 
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. 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 an occlusal adjustment (D9952 x2). 
 
You asked the Plan to pre-approve an occlusal adjustment. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue 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 an 
occlusal adjustment (D9952 x2).