Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care can be safely managed at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as she does not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. This patient does not show any abnormal behaviors or any symptoms which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she does not have dangerousness to self or others and was compliant with her treatment. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT should be covered because you have less pain and more range of motion after therapy sessions. The Plan denied your request. The Plan says you do not meet Medicare criteria for additional PT.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not support coverage for additional physical therapy visits. You should be able to do home exercises. The requested therapy is not generally accepted as specific and effective therapy for your condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. You may benefit from further medical evaluation of the pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the authorization of an inpatient hospital admission for 
Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, 
transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when 
performed, and radiological supervision and interpretation (33340). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that your request is not medically necessary because your CHADS2 
and CHA2DS2-VASc scores are below the required threshold, you have not had any formal shared decision 
making with a non-interventional physician regarding this procedure, and there is no documented 
contraindication to long-term oral anticoagulation. 
 
The Plan follows Medicare rules. Medicare rules say that these services can be covered if the NCD criteria is 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
these services are not medically reasonable and necessary. You have a history of atrial fibrillation. You do not 
have a history of hypertension, heart failure, diabetes, stroke, or blood clots. Your physician notes that you are 
currently on Eliquis for anticoagulation without any significant bleeding episodes. You would like to stop 
Eliquis since you are very active and are concerned with bleeding risk. You had a clinic visit with an 
Electrophysiologist regarding the Watchman procedure. The review has determined that you are able to use 
oral anticoagulants. Our physician reviewer found that your condition does not meet Medicare criteria for these 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the authorization of an inpatient hospital admission for Percutaneous transcatheter closure 
of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter 
placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological 
supervision and interpretation (33340).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) with an 
ophthalmologist provided on June 10, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that these services were necessary. The 
Plan denied your request. The Plan says this copayment was 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 $25 
copayment for an office visit with a specialist.

You have been asked to pay a $25 copayment for the office visit with an ophthalmologist. An ophthalmologist 
is a specialist. 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 (99214) with an 
ophthalmologist provided on June 10, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 

There is not a reasonable expectation that the 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 pay for an ultrasound and mammogram provided on April 20, 2021.
You asked the Plan to pay for the ultrasound and mammogram. The Plan denied your request. The Plan says
members must use in-network providers to get medical care and services. The only exceptions are emergencies,
urgently needed care, when the network is not available (generally, when member is out of the area), out-ofarea
dialysis services, and cases in which the Plan authorizes 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 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 an ultrasound and mammogram provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the OON provider on
September 30, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99213) rendered by the OON provider on September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary
osteoarthritis of the knees. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The
records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa is
not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on December 28, 2020.
You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on December 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.
You asked the Plan to pre-approve the additional skilled nursing visits. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says medical necessity cannot be established for continued coverage for the request for skilled nursing services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional skilled nursing visits. Our reviewer says that the enrollee does not meet the Medicare criteria for the skilled nursing services. Our physician reviewer found based on the medical records provided there is no documentation that that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration for the four denied visits. Notes indicate the enrollee's wound is almost healed and that her caregiver can perform dressing changes when the nurse is not available. The provided records do not indicate why the total of 13 skilled home health nursing visits are inadequate to treat the enrollee's condition. 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 additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the magnetic resonance imaging (MRI) of any joint of the lower extremity; without contrast material (73721) provided on July 8, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $300 copayment for each Medicare-covered diagnostic imaging service. You have been asked to pay $231.25 for the Medicare-covered diagnostic imaging service provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment.
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 adjust the copayment for the magnetic resonance imaging (MRI) of any joint of the lower extremity; without contrast material (73721) provided on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
does not require transfer to LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80324, 80332, 80335, 80346, 80348, 80349, 80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80365, 80367, and 80369) provided on March 18, 2020.
You asked the Plan to pay for the laboratory services. 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. We looked at the file and Medicare rules. In this case, CPT codes 80324, 80332, 80335, 80346, 80348, 80349,
80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80365, 80367, and 80369 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (80324, 80332, 80335, 80346, 80348, 80349, 80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80365, 80367, and 80369) provided on March 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on May 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line
on which the first four positions of the HIPPS code match the code submitted on the RAP.
We looked at the file and Medicare rules. The file shows that the home health claim was not billed with the
required 0023 revenue code. Therefore, we decided that the Plan does not have to pay for the home health
services rendered on May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has osteopenia. The
records do not support that the criteria for coverage of Prolia are met. The requested Prolia is therefore not
reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and mandibular
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests,
and teeth) (D5214) provided June 11, 2020.
You asked the Plan to pay for the complete upper denture and partial lower denture. You say that you were told
that dentures were separate from your annual dental amount. The Plan denied your request. The Plan says you
have exceeded your dental annual maximum; therefore, the requested services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine dental
services including complete upper denture and partial lower denture up to a $2,500 maximum.
We looked at the file and Medicare rules. The Plan provided documentation showing that you used your full
$2,500 dental allowance prior to the requested services. Therefore, we decided that the Plan does not have to
pay for the complete denture - maxillary (D5110) and mandibular partial denture - cast metal framework with
resin denture bases (including retentive/clasping materials, rests, and teeth) (D5214) provided June 11, 2020.
Your complaint about potentially being provided misinformation by a Plan representative is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints.