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

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is too complex for skilled 
nursing care as this venue, under the circumstances, poses significant risk for another re-admission. The Plan 
denied your request. The Plan says the service requested is not supported based on the records we received. 
 
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. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with fascial dehiscence and 
evisceration status post recent exploratory laparotomy with colectomy. The course was complicated by a 
urinary tract infection, COPD (on home oxygen), and fluid overload. The enrollee was treated with exploratory 
laparotomy with reclosure, antibiotics, diuresis, blood transfusion, and wound care. Recent notes describe the 
enrollee with stable vitals and tolerating and responding to current treatment.  
 
 The enrollee does not require complex wound care. The enrollee appears to be more stable and improving and 
should only require short-term additional acute care services that can safely be administered at the current 
facility until more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for screening colonoscopy to a diagnostic 
provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for screening colonoscopy to a diagnostic. You say that this was 
supposed to be a screening and not diagnostic. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for screening colonoscopy to a diagnostic. This item/service 
falls within the outpatient hospital 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 screening colonoscopy to a 
diagnostic provided on May 16, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance image (MRI) of the pelvis without and with 
contrast (72197). 
 
You asked the Plan to pre-approve an MRI of the pelvis without and with contrast. You say that the service is 
medically necessary. The Plan denied your request. The Plan says that there is no documentation of pelvic 
region pain and no specific documentation provided to support how the MRI test results will impact the 
treatment of the enrollee. 
 
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 an MRI of the pelvis without and with 
contrast. Our reviewer says that the service is necessary, and the enrollee meets criteria for coverage. Our 
physician reviewer found the consultation note specifically describes the plan to use the MRI for treatment 
planning which is a standard of care means to best identify the prostate as well extent of extracapsular 
extension. The MRI would aid in treatment decision making as it will be used for radiation planning. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the pelvis without and with contrast have been met. Therefore, we 
decided that the Plan has to pre-approve a magnetic resonance image (MRI) of the pelvis without and with 
contrast (72197).  
 
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 the enrollee requires inpatient acute rehabilitation in 
effort to facilitate increased independence and return home, and to his community with improved quality of 
life. The Plan denied your request. The Plan says the member 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 while the enrollee may benefit from continued physical and occupational therapy, the 
enrollee's rehabilitation needs can be safely provided in 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the boot strapping procedures provided on 
January 05, 2022, to May 09, 2022. 
 
You asked the Plan to waive the copayment for the boot strapping procedures. You say that the doctor only 
took the strap on and off to look at the wound. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $395 
copayment for surgery or other services provided at an outpatient hospital. 
 
You have been asked to pay a $395 copayment for the boot strapping procedures. This item/service falls within 
the surgery or other services provided at an outpatient hospital 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. The allowed amount for the boot strapping 
procedures is $139.56. Since this is less than the EOC copayment of $395, you are only responsible for the 
lesser amount. The file shows a total of 14 visits for these procedures, for a total of $1,953.84. Therefore, we decided that the Plan does not have to waive the copayment for the boot strapping procedures provided on 
January 05, 2022, to May 09, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous (IV) iron therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have documented iron deficiency anemia and has not failed oral iron. 
 
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 the requested services. Our physician 
reviewer found that the enrollee's hemoglobin and hematocrit were normal on testing. The documentation does 
not support that IV iron is medically reasonable and necessary for the enrollee. The documentation does not 
support that IV iron is safe and effective for the enrollee. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intravenous (IV) iron therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the service was medically necessary. The 
Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 74022.  
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 71045 
is a column II code to column I code 74022. 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 procedure code 71045 billed for date of service March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission a LTACH is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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. Our 
physician reviewer found that there is no evidence that the enrollee requires services that are not currently 
available. The enrollee can remain at the current acute care hospital until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is currently on high flow 
nasal cannula and their needs cannot be met at any skilled nursing care facility.  The Plan denied your request. 
The Plan says based on Medicare guidelines and the information we have about the enrollee's condition they do 
not meet all the requirements. 
 
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. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with acute respiratory failure 
COVID-19 pneumonia and pulmonary embolism in the setting of pulmonary fibrosis requiring increased 
oxygen support beyond baseline, anticoagulation treatment, and care for chronic sacral wounds. The enrollee 
was recommended for a lung transplant and recent notes describe the enrollee as tolerating weaning but still 
requiring high flow oxygen support.  
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can safely be administered at the current facility until more stable and appropriate for a lower 
level of care. The enrollee does not require services at the LTACH that are not available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
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 now requesting IRF admission so the member could 
possibly go home alone. The Plan denied your request. The Plan says the member does not meet the Medicare 
criteria for admission to an 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 member does not require increased physician oversight for her current medical 
conditions and does not require the intensity of rehabilitation physician oversight provided in the acute 
inpatient rehabilitation setting. Our physician reviewer also found that the member's medical and rehabilitation 
needs do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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: 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 enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says IRF is not 
medically necessary, and the enrollees needs can be met at a lower level of care such as skilled nursing facility 
(SNF), home health or 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 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on March 9, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim was initially filed 
with a different plan. You also say that the claim should be reprocessed and paid. The Plan denied your request. 
The Plan says the claim denied correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the evaluation and management service was not filed until May 17, 2021. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on March 9, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
December 8, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the providers only provided medically 
necessary services in good faith. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cast application provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for the cast application. You say that you were seen in an office 
setting but billed as an outpatient. The Plan denied your request. The Plan says this cost sharing was charged 
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 $100 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
 
You have been asked to pay a $100 copayment for the cast application. This item/service falls within the 
Outpatient Surgery and Other Medical 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 the cast application 
provided on April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the facility should have obtained the prior 
authorization. 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on May 24, 2022, 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. The Plan denied your request. The Plan says there 
are not enough studies on Intracept to show it is safe and effective. 
 
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 Intracept procedure is considered experimental. 
 
  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.