Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on April 19, 2021. 
 
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 (99214) rendered by the out-of-network (OON) provider on April 19, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on 
July 19, 2021, billed with code 76700. 
 
You asked the Plan to pay for the ultrasound interpretation. You say that this should be paid because the patient 
had multiple exams on the date of service. The Plan denied your request. The Plan says the patient had multiple 
exams, but this is not billed correctly to allow for payment due to the missing modifier. 
 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 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on July 
19, 2021, billed with code 76700.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) and a complete 
denture - mandibular (D5120) provided by a participating provider on March 29, 2021. 
 
You asked the Plan to pay for a complete denture - maxillary (D5110) and a complete denture - mandibular 
(D5120). You say that you were told that these dentures would be covered. The Plan denied your request. The 
Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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 a complete 
denture - maxillary (D5110) and a complete denture - mandibular (D5120) every five years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete denture - maxillary (D5110) and a complete denture - mandibular (D5120) have not been met. Evidence was provided to show that dentures services were provided on March 28, 2018. Therefore, 
we decided that the Plan does not have to pay for a complete denture - maxillary (D5110) and a complete 
denture - mandibular (D5120) provided by a participating provider on March 29, 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 enrollee has had strokes in the past. You also say 
that you feel a rehabilitation center would be the best decision for the enrollee to obtain her cognitive and 
physical abilities again. The Plan denied your request. The Plan says the enrollee's needs can be provided at a 
lower level of care. The Plan also says that the IRF admission is not medically necessary. 
 
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 provided documentation does not show that the enrollee does not have 
complex nursing or rehabilitation needs. The reviewer found that the enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the documentation does support a need for physical and/or occupational therapy, there 
is no documented need for an intensive, multi-disciplinary rehabilitation program. The reviewer also found that 
there is not a reasonable expectation that this patient 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. Specifically, the file shows there is no documented 
need for an intensive, multi-disciplinary rehabilitation program. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 9, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does not meet prudent layperson criteria for emergency care. A prudent layperson 
would not reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on 
December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myoelectric elbow/wrist/hand/finger orthosis for the 
enrollee. 
 
You asked the Plan to pre-approve the item. You say that this device is supported as an appropriate 
intervention. The Plan denied your request. The Plan says this is 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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the myoelectric 
elbow/wrist/hand/finger orthosis at issue in this case meets Medicare criteria for being medically reasonable 
and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with 
dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. Of 
the medical records provided in this case none of the treating physician encounter notes recommend 
the myoelectric elbow/wrist/hand/finger orthosis for treatment of 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a myoelectric elbow/wrist/hand/finger orthosis for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the physician services (procedure code J3490 and 97032) provided to 
the enrollee on January 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this does not meet coding standards. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Current Procedural Terminology (CPT) definition of the denied codes is: 
 
CPT 97032: 
 
Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes 
 
Healthcare Common Procedure Coding System (HCPCS) J3490: 
 
Unclassified drugs 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has denied these codes, stating that "they do not meet coding 
standards." The plan has not stated what coding standards and guidelines were not followed in this case. There 
were no instructions on how to correctly resubmit the claim. Therefore, we decided that the Plan has to pay for 
the physician services (procedure code J3490 and 97032) provided to the enrollee on January 4, 2021.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve the wireless capsule endoscopy. The Plan denied your request. The Plan 
says the records do not show that you have had an esophagogastroduodenoscopy (EGD) and colonoscopy 
within the last 12 months. 
 
The Plan follows Medicare rules. Medicare rules say that a Colon Capsule Endoscopy (CCE) is not medically 
necessary for patients with known or suspected gastrointestinal obstruction, stricture, or fistula. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the wireless capsule endoscopy is not medically reasonable and necessary. Our physician 
reviewer found you have chronic anemia, but no documentation was provided of iron deficiency nor 
gastrointestinal blood loss. Our reviewer found that there has been no recent esophagogastroduodenoscopy 
(EGD), or colonoscopy performed. Our physician reviewer also found that of concern, your history of small 
bowel obstruction is a contraindication to capsule endoscopy performance. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level of care to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON tertiary care services. You say that appointments with providers in our area are 14 months out. The Plan denied your request. The Plan says medically necessary care is available in network. The Plan says that there is no supporting documentation that a higher level of care at a tertiary level facility is needed for the enrollee's chronic conditions.
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 provider at issue in this case is not a network provider with the Plan. 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 OON tertiary care services. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found there is no specific clinical rationale for the requested out-of-network services at the Clinic.
The documentation indicates that the enrollee has never been seen by in-network specialists requested. The review has determined that the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in network non-tertiary level of care provider. There is not anything unique about the enrollee's condition that that would make it medically necessary for her to see the requested out-of-network provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. There is no documentation provided indicating that tertiary level of care is 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 the OON tertiary care services have not been met. 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 the OON tertiary care services. Therefore, we decided that the Plan does not have to pre-approve a tertiary level of care to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a primary care office visit provided on March 12, 
2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you are appealing this claim. The Plan 
denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay $0 copayment for primary care office visit. The treating 
provider for this visit is a primary care provider, therefore the specialist copayment does not apply to this 
claim. 
 
The Plan says you must pay $25 copayment for office visit. Based on the Plan contract, however, you cannot 
be asked to pay more than $0 copayment for office visit. Therefore, we decided that the Plan has to waive the 
copayment for a primary care office visit provided on March 12, 2021.  
 
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. 
 
Please note that this decision is only regarding the office visit on March 12, 2021. Please contact the Plan 
regarding appeals for any other items or services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for intradialytic parenteral nutrition therapy for
the enrollee.
You asked the Plan to provide coverage for intradialytic parenteral nutrition therapy. You say that this
treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are
not met. The QIC overturned the Plans denial. The Plan requested a reopen and stated that we did not
apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for intradialytic parenteral nutrition therapy. The medical records show the on June 6, 2021 the enrollee
weighed s 212.7 pounds with no documentation of recent or severe weight loss. There was no documentation to
support the enrollee had severe pathology of the alimentary tract which does not allow absorption. While this
treatment may have been beneficial for the enrollee, the required criteria for this treatment were not met at the
time it was requires. Therefore, we decided that the Plan does not have to provide coverage for intradialytic
parenteral nutrition therapy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation for a new or established 
patient (D0150) provided on July 5, 2021. 
 
You asked the Plan to pay for the dental service. You say that you coverage includes 2 cleanings per year and 
x-rays. You say that the contract provider did not perform these services. You say that when you needed 
additional services, you chose to see a dentist that abides by the contract. You also say that you feel the 
frequency limit should be excused due to the actions of the previous contracted provider. The Plan denied your 
request. The Plan says comprehensive oral evaluation is covered once every 3 years. The Plan also says that the 
frequency limit has been exceeded. 
 
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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is a 
covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on December 22, 2020. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation for a new or established patient (D0150) provided 
on July 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux. 
 
You asked the Plan to pre-approve Erbitux. You say that the requested Erbitux is medically necessary. The 
Plan denied your request. The Plan says the requested Erbitux is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Erbitux. Our reviewer says that the 
requested Erbitux is not medically necessary. Our physician reviewer found the requested use of Erbitux is not 
FDA-approved for the enrollee's diagnosis. The enrollee has not received irinotecan-based therapy. The 
requested use in this case is not supported by any of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. The requested Erbitux is not medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Erbitux have not been met. Therefore, we decided that the Plan does not have to pre-approve Erbitux.