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 your well-being is a risk for regaining maximum 
function. You say intensive care and therapy is required and cannot be provided in a lower rehabilitation 
setting. The Plan denied your request. The Plan says authorization denied because IRF is not medically 
necessary and your needs can be met at a lower level of care such as a skilled nursing facility (SNF), home 
with home health services, or 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 your medical problems are stable and 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 you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two resin-based composites - one surface, posterior 
(D2391) provided September 8, 2021. 
 
You asked the Plan to pay for the two fillings. You say that your provider should have verified your benefits. 
The Plan denied your request. The Plan says you have exceeded the frequency limit for fillings, therefore the 
third and fourth fillings have been denied. 
 
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 two fillings 
per year. 
 
 We looked at the file and Medicare rules. The Plan provided documentation showing that two fillings were 
covered on the same date of service.  Therefore, we decided that the Plan does not have to pay for the third and 
fourth resin-based composites - one surface, posterior (D2391) provided September 8, 2021.  
 
Your complaint about feeling the network provider did not adequately verify your benefits is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
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 would benefit from inpatient 
rehabilitation. The Plan denied your request. The Plan says denied authorization because IRF is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollee's medical problems are stable and 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 enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay provided from April 29, 2021, to May 12, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient stay. You say that it was medically necessary to treat the enrollee. 
The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was 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 an inpatient stay provided from April 29, 2021, to 
May 12, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on the perineum (00902) provided 
on November 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia for procedures on the perineum. You say that you do not have a 
referral on file. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan, and they have also determined that these services are not urgent or emergent, nor were they approved in 
advance. The Plan also says that there is not a referring 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 anesthesia for procedures on the perineum (00902) 
provided on November 22, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx pens. 
 
You asked the Plan to pre-approve Cosentyx pens. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx pens.  
 
Benefits for Cosentyx pens 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: 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 acute level of care is more intense and aggressive 
and the medical management with closer physician supervision than she would receive at the sub-acute 
rehabilitation level. You say the enrollee's goal is to go home in 7-10 days and not be in a nursing home. The 
Plan denied your request. The Plan says authorization denied because the IRF care is not medically necessary, 
and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollee's medical problems are stable and 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 enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on 
October 28, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $5 
copayment for provider and professional services rendered in a primary care physicians (PCP) office.  
 
 You have been asked to pay a $5 copayment for the provider and professional services rendered by a primary 
physician. This claim was previously paid by the Plan with a member copayment liability. 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 office visit (99213) provided on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the anesthesia for diagnostic procedure (01992). 
 
You asked the Plan to pre-approve the anesthesia for diagnostic procedure. You say that you would like this 
claim reprocessed for medical necessity. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions absent any unique circumstances. 
 
We looked at the file and Medicare rules. No rare or unique circumstance has been presented for the medical 
necessity of the requested general anesthesia in conjunction with the facet joint injections. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia for diagnostic procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the anesthesia for diagnostic 
procedure (01992).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy (52000) provided on 
November 22, 2021. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. 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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
  You have been asked to pay a $295 copayment for a cystourethroscopy. The cystourethroscopy falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a cystourethroscopy 
(52000) provided on November 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 4, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that your primary care physician advised 
you to go to the ER for a breathing treatment. You also say you should not be responsible for the copayment 
because you were unable to be seen in the office due to COVID-19 restrictions. 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 $90 
copayment for an in and out of network emergency room visit.  
 
You confirmed that you received a breathing treatment in the emergency room on October 4, 2021. You have 
been asked to pay a $90 copayment for an ER visit. An ER visit falls within the Emergency 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 an emergency room (ER) visit provided on 
October 4, 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 IRF is medically necessary. She states the 
enrollee meets all the criteria and it is critically important he receive that rehabilitation. The Plan denied your 
request. The Plan says authorization denied because IRF is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollee's medical problems are stable and 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 enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets full IRF criteria. The 
Plan denied your request. The Plan says authorization denied because the IRF care is not medically necessary, 
and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 enrollee has 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 enrollee has a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the needed clinical notes were not received. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at the file and Medicare rules. Despite multiple attempts by the plan, relevant medical records were 
not received to verify the need for this request. Based on this information, we decided that Medicare rules for 
coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve the office visit. You say that you want to see your preferred provider. The 
Plan denied your request. The Plan says there are in-network providers in your area accepting new patients. 
 
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 
an office visit to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), a bevacizumab 
injection (J9035), an injection of an eye drug (67028), and the scanning of computerized ophthalmic diagnostic 
imaging (92134) provided on September 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, a bevacizumab injection, an injection of an eye 
drug, and the scanning of computerized ophthalmic diagnostic imaging. You say that it is your position that 
payment is warranted, and that although it is unclear why authorization was not obtained, these services were 
necessary in order to treat the patient. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and a referral was not authorized by the primary care physician (PCP). The Plan also says that they have also determined that these services are not urgent, emergent, nor were they 
approved in advance. 
 
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 a hospital outpatient clinic visit (G0463), a 
bevacizumab injection (J9035), an injection of an eye drug (67028), and the scanning of computerized 
ophthalmic diagnostic imaging (92134) provided on September 9, 2021, by an out-of-network (OON) provider.