Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that the treatment the enrollee received was medically 
necessary. 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 
psychotherapy. We found no exception that would require the Plan to pay for the psychotherapy. The records 
provided for review do not show that the psychotherapy was urgent or emergent. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on January 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional physical therapy (PT) is medically 
necessary. The Plan denied your request. The Plan says the criteria for additional PT sessions have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the home exercise plan is a short-term goal to be met in 2 weeks thus 
the 6 additional visits approved by the Plan would suffice, and enrollee would not be expected to require the 
skills of a professional therapist after that time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132) 
and psychological or neuropsychological test administration and scoring by technician (96138). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring by technician. You say that the enrollee requires a 
NeuroTrax memory test due to the worsening of his memory loss. The Plan denied your request. The Plan says 
neuropsychological testing is not reasonable or necessary at this time. 
 
The Plan follows Medicare rules. Medicare rules say that testing which is intended to diagnose and characterize 
the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 
 
 
 
 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 neuropsychological testing evaluation 
services and psychological or neuropsychological test administration and scoring by technician. Our reviewer 
says that these services are not reasonable and necessary. Our physician reviewer found the documentation 
shows the patient claims difficulty with amnesia. This patient suffers from Parkinson's disease and complains 
of hand tremors with memory loss. There are no office memory tests present. Our physician reviewer also 
found that this patient does not meet the criteria based on Local Coverage Determination (LCD) L33632 as the 
patient is not showing severity of symptoms that would warrant this type of diagnostic treatment and is 
therefore not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring by technician have not been met. Therefore, we decided 
that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132) and 
psychological or neuropsychological test administration and scoring by technician (96138).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient hospital visit provided on October 25, 2021. 
 
You asked the Plan to pay for the inpatient hospital visit. You say that the claim denied for missing patient 
medical records. The Plan denied your request. The Plan says that the Plan made payment according to the 
Medicare allowable rate. 
 
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. Specifically, the Plan has not provided documentation to support the denial. 
Therefore, we decided that the Plan has to pay for an inpatient hospital visit provided on October 25, 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 pay for inpatient hospital services provided from May 24, 2020, to 
May 26, 2020, at the diagnosis related group (DRG) billed. 
 You asked the Plan to pay for the inpatient care at the DRG billed. You say that this hospitalization should be 
paid as billed. The Plan denied your request. The Plan says the secondary diagnosis of N17.9 (acute kidney 
failure) is not supported in the medical record, resulting in a lower DRG being paid. 
 
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 a secondary diagnosis of N17.9 (acute kidney 
failure, unspecified). 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 inpatient care at the 
DRG billed. Our reviewer says that a secondary diagnosis of N17.9 (acute kidney failure, unspecified) is not 
supported in the medical record. Our physician reviewer found the documentation supported an admission for 
gastroesophageal laceration. The documentation was unclear regarding a diagnosis of acute kidney failure. The 
diagnosis of acute kidney injury (AKI) is not noted in the medical record provided nor was supporting 
documentation found within the record. This is a 74-year-old male with a past medical history of hypertension 
(HTN), Type 2 Diabetes, and chronic kidney disease (CKD). The patient presented for complaints of dizziness 
and two episodes of vomiting with bright red blood. After further emergency room evaluation, the patient was 
admitted for hematemesis, dizziness, diabetes, HTN, CKD stage 3, and thyroid nodule. The appeal letter 
mentions a patient may have AKI and CKD, an elevated creatinine level, and an increase in creatinine of 0.3 
mg from a baseline creatinine of 1.7 to 2.0. An elevated creatinine level in the presence of CKD stage 3 is 
noted with a rise of 0.3 mg/dL. There was no documentation of an increase of serum creatinine by 3.0 times 
high normal levels, and the patient did not have a GFR decrease > 75%, nor initiation of renal replacement 
therapy. 
 
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 hospital services provided from May 24, 2020, to May 26, 2020, at the diagnosis related group 
(DRG) billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing and an x-ray provided on 
January 26, 2022. 
 
You asked the Plan to waive the copayment for diagnostic testing and an x-ray. You say that you should only 
be charged the office visit copayment. The Plan denied your request. The Plan says the copayments applied are 
correct. 
 
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 $25 
copayment for x-rays and a $50 copayment for Medicare-covered outpatient diagnostic tests. 
 
 
 
 
 You have been asked to pay $100 total for the office visit, diagnostic testing, and the x-ray. Diagnostic testing 
and an x-ray fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 diagnostic testing and an x-ray provided on January 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that due to being short-staffed, you were not able 
to get authorization before the services were rendered. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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 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 medical services provided on March 2, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 15, 2022. 
 
You asked the Plan to waive the copayment for a specialist office. You say that you are approved for a program 
administered by the United States Department of Labor that covers all costs, including copayments, for 
treatment of these conditions. You also say that you have reminded this medical group every time you go for 
treatment, three times face-to-face with the billing department, and several times through the mail by enclosing 
literature with copayment bills you have returned. The Plan denied your request. The Plan says you were 
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 $35 
copayment for a specialist visit for Medicare-covered services.  
 
You have been asked to pay a $35 copayment for a specialist visit for Medicare-covered services for a 
specialist office. A specialist office falls within the physician/practitioner services, including doctors 
office visits 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 a specialist office visit provided on February 15, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility, at home with home health services or at home with 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 that while the enrollee may benefit from physical therapy, and occupational therapy, 
the enrollee's rehab needs can be safely met in an alternate and lower intensity 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 pay for nerve block services provided on February 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nerve block services. You say that you have provided records to support 
payment. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 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 nerve block services provided on February 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on December 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that although you are out-of-network, the enrollee cannot 
choose the radiologist who reads their report. 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 x-
rays. We found no exception that would require the Plan to pay for the x-rays. The records provided for review 
do not show that the x-rays were urgent or emergent. Therefore, we decided that the Plan does not have to pay 
for the x-rays provided on December 10, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient hospital visit provided on October 31, 2021. 
 
You asked the Plan to pay for the inpatient hospital visit. You say that the claim denied due to missing patient 
medical records, which you have submitted. The Plan denied your request. The Plan says that our systems do 
not show an active specialty for this provider. 
 
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. Specifically, the Plan has not provided documentation to support the denial. 
Therefore, we decided that the Plan has to pay for an inpatient hospital visit provided on October 31, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drug and the administration 
of the drug provided on January 12, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drug and the administration of the drug. You 
say that you dont understand why one treatment is so much money. The Plan denied your request. The Plan 
says the coinsurance applied is correct. 
 
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 20% 
coinsurance for each Medicare covered Part B chemotherapy drug and the administration of the drug..  
 
 
 
 
 You have been asked to pay $3,024 which is 20% of the allowed amount for the chemotherapy drug and the 
administration of the drug. The allowed amount is $15,122.44 (20% x $15,122.40= $3,024). Chemotherapy 
drugs and the administration of the drugs 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 waive the coinsurance for chemotherapy drug and the administration of the drug 
provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 19, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to show 
the necessity of the services. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
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 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 medical services 
provided on December 19, 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 is stable for transfer and requires close 
medical monitoring, as well as prolonged and intensive skilled therapy services that are not available at a lower 
level of care. The Plan denied your request. The Plan says the records do not show that the enrollee has daily 
intensive therapy needs. The Plan says that the services needed can be safely provided in other settings. 
 
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 
was admitted for confusion. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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.