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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 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 a lower level of 
care is more appropriate. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Completion of care at the current facility is recommended. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 18, 2021, to December 26, 2021. 
 You asked the Plan to pay for the services. You say that the Medicaid State agency (CMA) may file a request 
for an appeal with respect to a claim for items or services furnished to a dually eligible beneficiary only for 
services for which the Medicaid State Agency has made payment, or for which it may be liable. The Plan 
denied your request. The Plan says by December 18, 2021, clinically the enrollee's condition no longer required 
daily skilled services at an inpatient skilled nursing facility (SNF) level of care. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided, there 
is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse were not required to safely and effectively provide medically 
necessary and reasonable treatment from December 18, 2021 through December 26, 2021. The records did not 
document the need for intravenous medications, new tube feeding or ostomy care or daily complex wound care. 
He was noted to have redness to his bilateral heels but with no open areas; the skin was reported as intact. The 
patient did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a 
qualified therapist were not required to safely and effectively provide medically necessary and reasonable 
treatment from December 18, 2021 through December 26, 2021. Daily skilled services were not required. The 
enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in 
the nursing facility appear custodial 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from December 18, 2021, to 
December 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push-rim activated power assist device with associated 
components for a manual wheelchair. 
 
You asked the Plan to pre-approve push-rim activated power assist device. You say that you have nerve 
damage and issues in your hands so you are not able to push your chair. The Plan denied your request. The Plan 
says the denial of authorization for these components is correct, because you have not been evaluated by a 
qualified rehabilitation professional to determine if this is appropriate. 
 
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 push-rim activated power assist device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you are currently using a manual wheelchair for mobility in the home. 
There is no medical documentation to indicate that you are unable to accomplish mobility-related self-care 
tasks in the home with the current manual wheelchair. Therefore, the requested modifications including a push-
rim activated power assist device are not 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 push-rim activated power assist device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a push-rim activated power assist device with associated 
components for a manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic counseling (96040). 
 
You asked the Plan to pre-approve genetic counseling. You say that you believe you should see the genetic 
provider because it is medically necessary prior to starting hormone replacement therapy. The Plan denied your 
request. The Plan says genetic counseling cannot be paid as an individual service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96040 is medical genetics and genetic counseling 
services, each 30 minutes face-to-face with patient/family 
 
We find that CPT code 96040 is not supported in the medical record. Specifically, Per the National Physician 
Fee Schedule Relative Value file, Calendar Year 2022, genetic counseling (CPT 96040) falls under status code 
B. This states that payment for covered services are always bundled into payment for other services not 
specified. Based on this information, we decided that Medicare rules for coverage of genetic counseling have 
not been met. Therefore, we decided that the Plan does not have to pre-approve genetic counseling (96040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit and glucose; quantitative, 
blood (except reagent strip) provided on August 20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit and glucose; quantitative, blood (except reagent 
strip). You say that the patient had already established care with this provider and wishes to continue seeking 
services for this condition under this physician at this location. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan and the services were not referred by a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic visit and glucose; 
quantitative, blood (except reagent strip) provided on August 20, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be in an IRF because of his 
critical illness. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not 
been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 that the enrollee is medically stable and has no medical complexity. He does not need 
physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. At the current 
functional status, the enrollee does not need 3 hours a day five days a week of IRF therapies with 
interdisciplinary management. Long standing non-ambulatory status with dependency in activities of daily 
living and transfer will not change in 7-10 days as predicted with IRF stay. The complexity of the enrollee's 
nursing, medical and rehabilitation needs do not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitation care. While the enrollee may benefit from physical therapy and 
occupational therapy, his rehabilitation needs can be addressed at a low intensity alternate 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 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 Hospital outpatient clinic visit provided on February 1, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Hospital outpatient clinic visit. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Hospital outpatient clinic visit provided on 
February 1, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that denying the requested 
services could jeopardize the enrollee's physical well-being. You say that the office notes provided support the 
need for radiofrequency ablation services. The Plan denied your request. The Plan says the requested services 
are not medically necessary. 
 
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 radiofrequency ablation services. Our 
reviewer says that radiofrequency ablation services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is considered an experimental/investigational procedure because of 
the wide variation in efficacy in the peer reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Epidural injection provided on November 1, 2021. 
 
You asked the Plan to pay for an Epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Plan, this provider has not submitted any clinical records to support the medical 
necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an Epidural injection provided on 
November 1, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an Epidural 
injection provided on November 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services provided on 
November 6, 2021. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you only saw a nurse and 
you requested to see a doctor. The Plan denied your request. The Plan says medical records provided confirmed 
the enrollee saw a physician assistant-certified during the date of service. Therefore, the proper copayment was 
applied. 
 
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 Urgently needed services.  
 
  You have been asked to pay a $50 copayment for the urgent care services. The urgent care services 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 urgent 
care services provided on November 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an office visit, synvisc and cortisone 
injections provided on November 23, 2021, and January 5, 2022. 
 
You asked the Plan to waive the cost-sharing for the office visit, synvisc and cortisone injections. You say that 
the services should be covered as you disagree with the charges. 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 $20 
copayment for Physician/Practitioner services, including doctors office visits and a 20% coinsurance for 
Medicare Part B prescription drugs.   
You have been asked to pay a $40 copayment for 2 office visits and a 20% coinsurance for the synvisc and 
cortisone injections (total allowed is $566.64 x 20% = $113.32). 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 
cost-sharing for an office visit, synvisc and cortisone injections provided on November 23, 2021, and January 
5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a Part B compound drug administered on 
January 4, 2022. 
 
You asked the Plan to reduce the coinsurance for the Part B drug. You say that the cost is too much and you 
would like to go back to your lower copayment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% 
coinsurance for Part B prescription drugs.  
 
You have been asked to pay $52, which is 20% of the allowed amount for the Part B drug ($260 allowed 
amount x 20% coinsurance = $52). The Part B drug falls within the Medicare Part B Prescription Drugs 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 reduce the coinsurance for a Part B compound drug administered on 
January 4, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy services provided on 
January 18, 2022. 
 
You asked the Plan to waive the copayment for the psychotherapy services. You say that you are paying 2-3 
times more than previous visits. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $30 
copayment for each therapy telehealth visit.  
 
The file shows that the Plan reprocessed your claim to show the correct copayment of $30. The EOC confirms 
that telehealth visits are not subject to the deductible, but the copayment still applies. Therefore, you have been 
asked to pay a $30 copayment for the psychotherapy services. The psychotherapy services fall within the 
Outpatient Mental Health Care 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 psychotherapy services provided on January 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture. 
 
You asked the Plan to pre-approve acupuncture. You say that you want to see this provider for acupuncture. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
requested provider does not meet the requirements for coverage and you do not have chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that you have chronic low 
back pain which is required for coverage of acupuncture. Therefore, we decided that the Plan does not have to 
pre-approve acupuncture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this amount of nursing 
care because her wounds are very large, frequently swells, and needs proper dressing care. The Plan denied 
your request. The Plan says authorization denied because the LTACH is not medically necessary and the 
enrollee's needs can be met at a lower level of care such as an acute rehabilitation facility, skilled nursing 
facility, outpatient setting or home care. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can safely be administered at the current facility until a lower level of care is more 
appropriate. Transfer to LTACH is not medically necessary as it would not be clinically advantageous, and 
completion of care at the current facility is recommended. 
 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 long term acute care hospital (LTACH) services.