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

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 12, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 12, 2021, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 

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 care from 
November 12, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of November 12, 2020, forward. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment beyond November 12, 2021, as she was not 
a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for 
the purpose of diagnosis. 
 
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 care from November 12, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 12, 
2021, forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to 
be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be 
received at a different setting, for example, home with home health, in residential care, or home with close 
follow-up with your doctor. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to hold you harmless for the crown - porcelain/ceramic (D2740) for tooth #26 
provided June 8, 2021. 
 
You asked the Plan to hold you harmless for the crown for tooth #26. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that the service does not meet criteria for coverage. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. Additionally, 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. 
 
You were referred for the crown for tooth #26 by a contract provider. The file does not show that the Plan 
provided notice that the crown for tooth #26 would not be covered. Under Medicare rules, this means the 
crown for tooth #26 is considered approved by the Plan. Additionally, the Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request. In this 
case we requested the Plan?s criteria for coverage for crowns. The requested information was not received. 
Therefore, we decided that the Plan has to hold you harmless for the crown - porcelain/ceramic (D2740) for 
tooth #26 provided June 8, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a continuous positive 
airway pressure machine and supplies. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are available in-network. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral out-of-network for a continuous positive airway pressure machine and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 3, 2020. 
 
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 not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
19, 2021, to June 21, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford to pay 
for the services The Plan denied your request. The Plan says the copayment 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 $350 
copayment for Inpatient hospital care.  
 
You have been asked to pay a $350 copayment for 3 days of inpatient hospital care. 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 inpatient hospital care provided from June 19, 2021, to June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Kadcyla and Ondansetron for the enrollee. 
 You asked the Plan to pre-approve Kadcyla and Ondansetron. You say that the enrollee is not on a clinical trial 
for these drugs. The Plan denied your request. The Plan says that the requested drugs would be deemed a 
routine cost of the clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Kadcyla and Ondansetron as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve Kadcyla and Ondansetron for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (88361, 88312, 88305, 88104) provided on 
March 12, 201. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88361, 88312, 88305, and 88104 are not supported in the medical record. Specifically, 
the records show that the professional interpretation was furnished in a different payment locality from where 
the technical component was furnished. As such, the professional interpretation must be separately billed with 
modifier ?26 by the interpreting physician.  
 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 the services (88361, 88312, 88305, 88104) 
provided on March 12, 201.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided by a participating 
provider on April 3, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says that you have already exhausted your benefit limit for D0150. 
 
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 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 failed to provide an Explanation of Benefits to verify that D0150 
has been provided within the last three years. Therefore, we decided that the Plan has to pay for a 
comprehensive oral evaluation (D0150) provided by a participating provider on April 3, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) from an out-of-
network (OON) provider. 
 
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 available from 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 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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (PCD) from an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an inpatient admission provided from May 14, 2021, through 
May 18, 2021. 
 
You asked the Plan to pay for an inpatient admission. The Plan denied your request. The Plan says the facility 
must notify the Plan within 24 hours of an elective inpatient admission. 
 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 inpatient admission provided from May 14, 2021, through 
May 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says needs can be met at a lower 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 pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not 
qualify for SNF coverage, as you do not have documented skilled nursing or skilled therapy needs. You do not 
have a documented decline in function, and appear to be functioning at or near the baseline. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs, as a practical matter, can be provided at a lower level of care. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sixty (60) additional routine transportation trips. 
 
You asked the Plan to pre-approve sixty (60) additional routine transportation trips. You say that you require 
this transportation. The Plan denied your request. The Plan says that your request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to provide routine transportation above the benefit maximum of sixty (60) routine 
transportation trips. Therefore, we decided that the Plan does not have to pre-approve sixty (60) additional 
routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from April 27, 2020, to May 1, 2020, 
and billed with DRG (diagnosis related group) 939. 
 
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your 
request. The Plan says the records do not support diagnosis K65.1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 939, operating room procedures with 
diagnoses of other contact with health services with major complications or comorbidities, and diagnosis 
K65.1, peritoneal abscess. 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 inpatient care. 
Our reviewer says that the billed DRG is not supported. Our physician reviewer found the medical records 
provided do not include sufficient documentation to corroborate the validity of the peritoneal abscess diagnosis 
in association with the hospital stay.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient care provided from April 27, 2020, to May 1, 2020, and billed with DRG (diagnosis related group) 
939.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. The Plan states they could review alternate 
settings if requested such as a skilled nursing facility, outpatient setting or home health 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do 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 you 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen for the enrollee. 
 
You asked the Plan to pre-approve Epogen. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that this medication does not represent an expense to the physician and will not 
be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan 
does not have to pre-approve Epogen for the enrollee.  
 
Benefits for Epogen may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on June 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 70450 is a column II code to column I code 70496. 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 services (70450) 
provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (70450) provided on June 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 services (70450) provided on June 26, 2021.