Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from January 1, 2022, to January 3, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you feel that it should be covered 
since you were admitted. 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 $90 
copayment for each emergency room visit. You do not pay the cost share if you are admitted to the same 
hospital within 24 hours for the same condition.  
 The file shows that you were kept under observation status, and not admitted as an inpatient. Therefore, you 
have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit provided from 
January 1, 2022, to January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says according to the available records, the enrollee does not meet all the required Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. 
 
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 you are medically stable and does not need physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no rehab nursing needs identified in the record. At the current functional level, you do not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. Needs can be safely met in a skilled nursing facility 
(SNF). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for direct skilled nursing services provided to the enrollee from 
April 27, 2021, to May 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider was not yet certified at the time of service. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
 
 
 
 
 
 
 
 
 At the time of service, you were not eligible to bill Medicare. The plan did not pre-approve the services. We 
found no exception that would require the plan to pay for these items/services. 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 direct skilled nursing services provided to the enrollee from April 27, 2021, to May 4, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility (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 the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
living in a long-term care facility receiving care for a groin wound, and skin tear of the arm. There is ongoing 
weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for irrigation of implanted venous access device for drug 
delivery system provided on October 18, 2021. 
 
You asked the Plan to pay for irrigation of implanted venous access device for drug delivery system. You say 
that the member has already established care with this provider and would like to continue care with this 
provider. The Plan denied your request. The Plan says 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 Plan says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for irrigation of implanted venous access device for drug delivery 
system provided on October 18, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can safely be received in other settings, for example: 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 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 anemia and gastrointestinal bleeding. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the lower extremity joint magnetic resonance imaging (MRI) 
(73721). 
 
You asked the Plan to pre-approve the MRI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
service is medically necessary. Our physician reviewer found a six week trial of physical therapy is not 
necessary, based on patients medical history. An MRI would be indicated no matter the result of a plain 
radiographic image. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
the lower extremity joint magnetic resonance imaging (MRI) (73721).  
 
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 the radiographic/surgical implant index, by report (D6190) 
provided December 8, 2021. 
 
You asked the Plan to pay for the radiographic/surgical implant index. You say that these implants are 
medically necessary. The Plan denied your request. The Plan says this service is not covered under your 
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 pay for the 
radiographic/surgical implant index, by report (D6190) provided December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right L2-L5 radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services. You say that this is medically reasonable and necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met for the requested services. 
 
The Plan follows Medicare rules. Medicare rules say that RFA services are medically reasonable and necessary 
after at least 2 MBBs. 
 
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 RFA services. Our reviewer says that 
the requested RFA services are not medically reasonable and necessary. Our physician reviewer found In this 
case, there is no documentation of previous right MBBs. The review has determined that the enrollee does not 
satisfy the coverage criteria for the requested RFA 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 RFA services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right L2-L5 radiofrequency ablation (RFA) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84480) provided on June 30, 2021. 
 
You asked the Plan to pay for code 84480. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are 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. In this case, we have confirmed that code 84480 
is a column II code to column I code 84481. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (84480) provided on June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz (J7321). 
 
  You asked the Plan to pre-approve Supartz. You say that the enrollee previously underwent an Orthovisc 
injection series with good relief. You also say that the enrollee has tried and failed conservative therapy for 6 
months with no improvement. The Plan denied your request. The Plan says the enrollee does not have any 
stated contraindications to the preferred products, nor has the enrollee tried any of the preferred agents. The 
Plan also says that there is no rationale provided for the use of the non-preferred product for safety or efficacy. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Supartz. Our reviewer says that Supartz 
is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. Our reviewer found 
that the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that the 
documentation does not support that Orthovisc, Synvisc, or Synvisc-One would likely be less effective, and/or 
would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz (J7321).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for exploration of spinal fusion provided to the enrollee on 
August 5, 2021. 
 
You asked the Plan to pay for the services. You say that this code is inclusive to another billed code. The Plan 
denied your request. The Plan says this code is inclusive to another billed code. 
 
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 22830 is "Exploration of spinal fusion." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the operative report documents 
procedures performed on L4-S1. When procedures are performed at the same level as diagnostic services, the 
diagnostic service would be inclusive to the primary procedure. In this case, the exploration procedure was not 
performed on a separate structure, and therefore would not be reported separately. 
 We looked at this coder's review, the file, and Medicare rules. 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 exploration of spinal fusion provided to the enrollee on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast prosthesis (L8030) and mastectomy bra 
(L8000) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a breast prosthesis (L8030) and mastectomy bra (L8000) to be provided by 
an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your 
request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The 
Plan says there are in-network providers available and accessible to the enrollee that can provide the items 
being requested. 
 
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 
a breast prosthesis (L8030) and mastectomy bra (L8000) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 
for the enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary to improve quality 
of life and increase strength and endurance. The Plan denied your request. The Plan says these services are 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 pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found as of 3/24/22, 
the enrollee did not require any skilled nursing or rehab services on a daily basis. He was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a SNF level of care as of 3/24/22. The enrollee did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. The enrollees function was at or near his prior level 
of function and he could receive care at a lower level of care for further services. The enrollee could have 
continued to receive custodial care with intermittent rehab 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laryngoscopy with injection performed on 
December 17, 2021. 
 
You asked the Plan to waive the copayment for the laryngoscopy. You say that the provider informed you that 
there was no copayment. 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 $100 
copayment for surgery or other services provided at an outpatient hospital or ambulatory surgical center.  
 
 You have been asked to pay a $100 copayment for the laryngoscopy. The laryngoscopy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a laryngoscopy with 
injection performed on December 17, 2021.