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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for SNF services and can be treated in a 
lower level of care such as at home with home health services. 
 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 services. Our physician reviewer 
found that the enrollee does not have daily skilled nursing or therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional. Our physician reviewer found that the enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 22, 
2021, to December 24, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary. The Plan denied your request. The Plan says this admission could have been done at an observation 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the patient suffered a gunshot wound to her foot. The fire department arrived and 
controlled the bleeding with a trauma dressing and transported the patient to the emergency room (ER). Her 
vitals were stable in the ER and an x-ray showed comminuted first metatarsal fracture. Her laboratory tests 
were normal except for high platelet count. She was admitted for further management. During her hospital 
course, hematology was consulted for the thrombocytosis. It was discovered the patient had at least a 10-year 
history of thrombocytosis. Hydroxyurea was recommended as treatment and JAK2 mutation workup was 
ordered. Orthopedics evaluated the fracture and found a minimally displaced fracture of the first metatarsal and 
conservative treatment was recommended. The patient was observed without any acute event and was 
discharged home. The record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier ER and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 22, 2021, to December 
24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Watchman procedure.  
You asked the Plan to pre-approve Watchman procedure. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested procedure is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is only covered for certain indications. 
 
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 Watchman procedure. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found you have an elevated risk of thromboembolic stroke due to atrial fibrillation and 
elevated CHADS2VASC score. There is no apparent contraindication to anticoagulation. As such, guidelines 
would not support implantation of a LAAC in this setting. Therefore, you do not meet criteria for the requested 
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 Watchman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Watchman procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 31, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to appeal the denial of the claim. The Plan 
denied your request. The Plan says it is the providers responsibility to check members eligibility and secure any 
authorizations prior to rendering services. 
 
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 an x-ray provided on January 31, 2022, by an out-
of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient stay is medically 
necessary. The Plan denied your request. The Plan says that the criteria for an inpatient hospital stay has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the inpatient psych ward was unable to accommodate O2 therapy therefore the member was 
admitted to medical floor and psych was to evaluate the member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for acute inpatient hospital care.  
 
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the medical criteria for an IRF admission has not been met. 
 
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 was admitted for surgical repair of a femur fracture after a fall. Medical 
problems are stable and there are no complex nursing or rehabilitation needs.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that you are unable to walk without assistance. The 
Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. There is insufficient published clinical literature demonstrating 
safety and effectiveness. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on March 3, 
2022. 
 
You asked the Plan to pay for replacement graft. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a bone replacement graft (D7953) is not covered by your dental 
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 a bone 
replacement graft (D7953) provided on March 3, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services. 
 
You asked the Plan to pre-approve the requested services. You say that you would be most helped by a 
Christian therapist. The Plan denied your request. The Plan says you must obtain services from providers who 
are certified to see Medicare members. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The rules say that no 
provider shall receive payment for services unless the provider is enrolled in the Medicare program. 
 
The requested provider in this case is not a network provider with the Plan. The provider is not enrolled in the 
Medicare program. We found no exception that would require the Plan to pre-approve the requested services. 
Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient consultation for second opinion to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient consultation. You say that you would like a second opinion 
from a research/student hospital which may have updated medical treatment options. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 
outpatient consultation for second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on March 7, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that these drugs were given to you during a 
medical procedure, and were not self-administered. The Plan denied your request. The Plan says self-
administered drugs are not Part B covered. 
 
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 pay for the self-administered drugs 
provided on March 7, 2022.  
 
Benefits for the self-administered drugs 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation 
provided on February 11, 2022. 
 
You asked the Plan to waive the copayment for the emergency ambulance transportation. You say that you 
have been spending a lot of money since you were hospitalized, and would like help with your case. The Plan 
denied your request. The Plan says the copayment amount you are being charged 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 a $265 
copayment for emergency ambulance transportation.  
 
 
 
 
 
 
 You have been asked to pay a $265 copayment for the emergency ambulance transportation. Emergency 
ambulance transportation falls within the Ambulance 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 emergency ambulance transportation provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hereditary cardiovascular genetic testing provided 
on July 1, 2021. 
 
You asked the Plan to pre-approve the testing services. You say that the denied codes are payable as billed. The 
Plan denied your request. The Plan says there is no benefit for risk assessment testing for asymptomatic 
patients. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The testing at issue was ordered based on the enrollees history. 
However, the records do not show that the enrollee was symptomatic. Pre-symptomatic genetic tests and 
services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not 
covered. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the hereditary cardiovascular 
genetic testing provided on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Supply allowance for therapeutic continuous glucose monitor 
(CGM) (K0553) provided August 26, 2021. 
 You asked the Plan to pay for the CGM supply allowance. You say that you have attached all the supporting 
documentation. Please reprocess the claim. The Plan denied your request. The Plan says the enrollee is not on 
insulin and does not meet the criteria. 
 
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 indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM supply allowance have not been met. 
Therefore, we decided that the Plan does not have to pay for Supply allowance for therapeutic continuous 
glucose monitor (CGM) (K0553) provided August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
July 14, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the correct codes were 
billed, and no coding changes were required. You say that the attached information should be reviewed and 
reconsidered for payment. The Plan denied your request. The Plan says the submitted medical records do not 
support hospital discharge day management of more than 30 minutes was performed. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not document 
discharge management services of more than 30 minutes was performed as required by the CPT code billed. 
Based on this information, we decided that Medicare rules for coverage of hospital discharge day management 
(99239) have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management (99239) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested  
out-of-network provider.  
 
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. The 
Plan denied your request. The Plan says with limited exceptions, while the member is enrolled in the Plan, the 
member must use network providers to get medical care and services. The only exceptions are emergencies, 
urgently needed care when the network is not available, out-of-area dialysis services, and cases in which the 
Plan authorizes the use of out-of-network providers. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexlizet. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Nexlizet.  
 
 
 
 Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF placement with active and 
ongoing therapeutic care of physical and occupational therapy with a minimum of 3 hours of therapy daily. The 
enrollee also requires close medical monitoring with 24 hours nursing oversight. The Plan denied your request. 
The Plan says the enrollee does not meet the 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 the enrollee was admitted for a fall, alcohol intoxication, and hypokalemia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical 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 IRF admission and services.