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

 
We decided that the Plan does not have to pre-approve right revision shoulder arthroplasty for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show specifics on what conservative treatments have been tried. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, there are no formal imaging studies 
provided for review to corroborate shoulder pathology that could benefit from the requested surgery. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the request for right revision shoulder arthroplasty is not 
medically reasonable or 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right revision shoulder arthroplasty for the enrollee.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications and had stable 
vital signs. You were at a moderate to maximal assist level for functional mobility including gait to 10 feet. 
You do not require skilled nursing or therapy services on a daily basis. You do 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 the office visit provided on September 15, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you called to see if there was a 
copayment before you went. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Medicare- covered services provided at a Convenient Care Center. Convenient Care Centers are 
walk-in healthcare clinics that specialize in the treatment of common illnesses and provide basic health 
screening services.   You have been asked to pay a $50 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 office visit 
provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine ophthalmological examination including refraction 
provided on October 5, 2021. 
 
You asked the Plan to pay for the routine ophthalmological examination including refraction. The Plan denied 
your request. The Plan says you received an annual vision exam on March 13, 2021. 
 
  Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services 1 per calendar year. 
 
We looked at the file and the Plan's rules. The file shows that you received the routine vision benefit on  
March 13, 2021, and have exceeded the benefit. Based on this information, we decided that the Plan's rules for 
coverage of the routine ophthalmological examination including refraction have not been met. Therefore, we 
decided that the Plan does not have to pay for a routine ophthalmological examination including refraction 
provided on October 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided from 
November 18, 2021, to November 19, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that the services 
should be covered as you don't understand why you are being billed $200 as it was only an er vizit. The Plan 
denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $200 
copayment for Outpatient hospital obvservation. 
 
 
 You have been asked to pay a $200 copayment for the outpatient hospital services. The record indicates that 
you went in for an emergency room visit but were admitted and set under observation status, the copayment for 
emergency care was waived and the outpatient observation copayment was applied. 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 outpatient hospital services provided from November 18, 2021, to November 19, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) 
provided on July 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you were compliant with regulations and these 
services were billed correctly. The Plan denied your request. The Plan says this claim was billed with an 
incorrect place of service (POS) code and is therefore denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We find that CPT code 0242U is not supported in the medical record. Specifically, this claim was billed with 
the laboratory place of service code while the records indicate that the members face-to-face service was 
rendered in an office setting. There is a more appropriate place of service code for the services billed. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) 
provided on July 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration provided on October 26, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chemotherapy administration. You say that the service was pre-authorized. 
 The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows the preauthorization was for J2323. Therefore, we decided that the Plan does not have to pay for 
chemotherapy administration provided on October 26, 2021, by an out-of-network (OON) provider.
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 was independent prior to their hospital 
stay but they need physical and occupational therapy to function on their own. The Plan denied your request. 
The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
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 rehabilitation needs can be met safely at a lower intensity and alternate 
setting such as in a skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered when combined with fusion, and when there has been fusion at 
another level. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested procedure includes both an anterior cervical discectomy and fusion at C6-7 and cervical 
disc arthroplasty at C5-6. There is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed for this 
hybrid technique. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for total disc arthroplasty at C5-6 is not 
medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total disc arthroplasty for the enrollee.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had 
stable vital signs and was treated for a UTI. The enrollee was at a modified independent to supervision/stand by 
assist level for functional mobility including gait to 500 feet. The enrollee does not require skilled nursing or 
therapy services on a daily basis. The enrollee 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 pay for the psychiatric diagnostic evaluation provided on April 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on April 11, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the member has tried and failed 
conservative treatments without relief. You say that this procedure fills a treatment gap for patients who do not 
receive adequate relief from conservative methods and the procedure is medically necessary. The Plan denied 
your request. The Plan says the requested procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support she has tried and failed any injections. 
Additionally, there were/are multiple plausible pathologic sources of significant pain generation. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the request for Intracept procedure at L5; S1 is not medically reasonable or 
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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you can 
safely receive the services you need 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that your 
high functional level requires this therapy on an intensive IRF level. On March 9, 2022, you were min assist for 
activities of daily living (ADLs). On March 10, 2022, you were ambulating 140 feet stand by assist (SBA) with 
rolling walker (RW), SBA for transfers and bed mobility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
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 
service is medically necessary. Our physician reviewer found the enrollee requires skilled therapy services. The 
documentation supports that it is medically reasonable and necessary to provide skilled therapy services on a 
daily basis, on 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on October 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the enrollee did not go to the laboratory, which 
means they did not use their out-of-network benefits since the participating doctor sent the specimen to process. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to 
pay for laboratory work provided on October 20, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a repair of long tendon of biceps (23430) provided on April 
19, 2021. 
 
You asked the Plan to pay for a repair of long tendon of biceps. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the procedure code at issue is inclusive 
to another billed code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 a repair of long tendon of biceps Our 
reviewer says that the service at issue does not meet criteria for reimbursement. Our physician reviewer found 
that the operative report does not support modifier -59 in this case, as there is no separate incision documented 
for both procedures reported, or different area procedure was performed. Therefore, modifier -59 cannot be 
verified.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repair of long tendon of biceps have not been met. Therefore, we decided that 
the Plan does not have to pay for a repair of long tendon of biceps (23430) provided on April 19, 2021.