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

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility, 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 requires only short-term additional acute 
care services that can safely be administered at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as 
it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment is 
completed.  
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skin biopsy provided on June 3, 2021. 
 
You asked the Plan to waive the copayment for the skin biopsy. You say that you were told there would only 
be a $25 copayment for the visit when you made the appointment. You say that no outpatient surgery was done, 
and you should not be charged. The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 $150 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges.  
  You have been asked to pay a $150 copayment for the skin biopsy. The skin biopsy falls within the "Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers" benefit category. The skin biopsy is considered a surgical procedure that was billed by the hospital. 
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 skin biopsy provided on June 3, 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 this is not medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, 
of therapy services. Therapy services may 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services provided on October 6, 2021, by a 
provider who has opted out of the Medicare program. 
 
You asked the Plan to pay for the dermatology services provided by a provider who has opted out of the 
Medicare program. You say that you would like the Plan to reconsider their denial of payment. The Plan denied 
your request. The Plan says the services are not covered when provided by a provider who has opted out of the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
dermatology services provided on October 6, 2021, by a provider who has opted out of the Medicare program.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87086, 87798, 87651, 87653, 87801, 
88363, 87481, 87640, 87500) provided on November 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this provider is not a contract provider with the Plan and the services 
were not authorized by network/primary care providers. The Plan also says that they have also determined that 
these services are not urgent or 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 laboratory services (87086, 87798, 87651, 87653, 
87801, 88363, 87481, 87640, 87500) provided on November 23, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee. 
 
You asked the Plan to pay for the admission. You say that this is needed after hospitalization related to 
community acquired pneumonia. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 admission. 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 requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. Records do not document the need for intravenous medications, new tube feeding or 
ostomy care or daily complex wound care. There is no documentation that daily skilled services are 
required. Services in a long-term care facility on a part time basis appear appropriate 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for an inpatient hospital stay 
provided from June 23, 2020, to July 14, 2020. 
 
You asked the Plan to waive the deductible and copayment for the inpatient hospital stay. You say that you 
already paid for the services and never received a detailed bill from the provider. The Plan denied your request. 
The Plan says the proper deductible and copayment was applied for the service. 
 
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 $1,000 
deductible and a $350 copayment per day, days 1-7. The deductible charged was $718.81 which is less than the 
chargeable deductible of $1,000. The charged copayment amount was $1,750 ($350 copayment daily amount x 
5 days). The total combined deductible and copayment amount was $2,468.81 ($718.81 deductible + $1,750 
copayment). You have been asked to pay a $718.81 deductible and a $1,750 copayment for the inpatient hospital stay. The 
inpatient hospital stay falls within the Inpatient hospital 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 deductible and copayment for an inpatient hospital stay provided from June 23, 2020, to July 14, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee.. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is a fall risk and it is unsafe to return 
home at this time. The Plan denied your request. The Plan says the services required can be safely received in a 
different setting, for example, perhaps with home health or in residential 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 services. 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. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee..
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oncology (thyroid) gene expression analysis of 10, 196 
genes (81546) provided on September 25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an oncology (thyroid) gene expression analysis of 10, 196 genes. You say that 
the ordering physician requested the sampled test, and you want this claim to be covered by the Plan. The Plan 
denied your request. The Plan says this provider is not a network provider, and the services were not referred 
by a network provider or rendered in a participating facility. The Plan also says that they have also determined 
that these services are not urgent or 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 an oncology (thyroid) gene expression analysis of 
10, 196 genes (81546) provided on September 25, 2021, by an out-of-network (OON) provider.
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 in an assisted living facility with home health services. 
 
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 
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing 
services. The specialized skill, knowledge and judgment of a skilled professional nurse are not required to 
safely and effectively provide medically necessary and reasonable treatment. There is insufficient 
documentation to support skilled therapy services on a "daily basis" on an inpatient basis, in a skilled nursing 
facility 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 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: 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 conditions is stable on outpatient medications with no issues that 
require a physicians evaluation three or more times per week. You do not require the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. Care in the home with home health services or 
at the skilled nursing facility level appears to be appropriate 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 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 coinsurance for the durolane injections provided on 
November 2, 2021. 
 
You asked the Plan to waive the coinsurance for the durolane injections. You say that the injection was 
supposed to take the pain away, but you are still in pain after two weeks. You say that the physician is 
overcharging, and you can't believe insurance is paying for it. The Plan denied your request. The Plan says the 
coinsurance applied correctly. 
 
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 Medicare Part B-covered chemotherapy drugs and other Medicare Part B covered drugs.  
  You have been asked to pay $457.94, which is 20% of the allowed amount for the durolane injections. The 
allowed amount is $2,289.70 (20% x $2,289.70 = $457.94). The durolane injections 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 the 
durolane injections provided on November 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the 
requested SNF services are medically necessary. The Plan denied your request. The Plan says all of the 
member's needs may be met at the inpatient rehabilitation facility and transfer to the SNF is not medically 
necessary. 
 
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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found this beneficiary does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 physical therapy home health visits. 
 
You asked the Plan to pre-approve the physical therapy home health visits. You say that you would like 
reconsideration because the additional visits are medically necessary. The Plan denied your request. The Plan 
says the member does not meet Medicare criteria for coverage of the 9 additional home health visits. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 physical therapy home health visits. 
Our reviewer says that the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the patient's condition and/or prevent deterioration. Our physician reviewer 
found the records do not show that skilled therapy services are required to effectively provide treatment, care, 
and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the patient's level of function and/or prevent deterioration, beyond the 6 additional visits 
approved by the plan. 
 
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 physical therapy home health visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 9 physical therapy home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve he Otto Bock 3R60 knee (L5814 + L5848) and the K3 
foot coded L5980. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is K3 ambulator and would benefit 
from this items. The Plan denied your request. The Plan says the documentation does not support that the 
enrollee is K3 so the requested knee and foot are denied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation from the enrollee's medical provider 
that supports that the enrollee is functioning at a K3 level. The provided records report the enrollee was 
approved for a group 2 power wheelchair in May 2019. The records report that the enrollee requires a 
wheelchair and cane for mobility. This is not consistent with a K3 ambulatory level to support necessity of the 
requested knee and foot system. 
 
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 pre-approve he Otto Bock 3R60 knee (L5814 + L5848) and the K3 foot coded L5980.