Persius/hicric huggingface dataset:
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 SNF admission. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 admission. Our reviewer says
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 the SNF 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment and coinsurance for magnetic resonance 
imaging (MRI) of the abdomen with contrast provided on August 3, 2021. 
 
You asked the Plan to reduce the copayment and coinsurance for the MRI with contrast. You say that you feel 
the contrast injection should not be a separate charge. The Plan denied your request. The Plan says the correct 
copayment and coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for radiological diagnostic services, not including X-rays. 
 
Your contract with the Plan clearly says that you must pay a 20% coinsurance for medical supplies, including 
chemical agents used in certain diagnostic procedures. 
 
You have been asked to pay a $150 copayment for the MRI. You have also been asked to pay $4.80 for the 
contrast agent, which is 20% of the allowed amount for medical supplies ($24.00 allowed amount x 20% 
coinsurance = $4.80). The MRI with contrast falls 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 reduce the copayment and 
coinsurance for magnetic resonance imaging (MRI) of the abdomen with contrast provided on August 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for occupational therapy services provided 
from August 4, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayments for the occupational therapy services. You say that you paid your 
$20 copayment each visit and that was all the provider told you it would be. 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 $40 
copayment for each occupational therapy visit at an outpatient hospital facility.  
 
The file shows that you had a total of 15 occupational therapy visits at an outpatient hospital facility from 
August 4, 2021, to September 30, 2021. Therefore, you have been asked to pay a $40 copayment for each 
occupational therapy visit. The total for all visits is $600 ($40 copayment x 15 visits = $600). The occupational 
therapy services fall within the Outpatient Rehabilitation Services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for occupational therapy services 
provided from August 4, 2021, to September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a
total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The
Plan says there is no documentation provided to support the expectation the enrollee will require a greater than
2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found the enrollee is approved for a total shoulder arthroplasty. The record does
not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more
midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
October 27, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you went back to have 
additional imaging a few days after your yearly mammogram. You also say that you should not be billed for a 
second, additional mammogram. 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 $65 
copayment for diagnostic mammography.  
 
 The record shows the service you received was a diagnostic mammogram. You have been asked to pay a $65 
copayment for an in-network diagnostic mammogram. A diagnostic mammogram falls 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 a diagnostic mammogram provided on October 27, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 you received oral medications and insulin. 
You had stable vital signs and were treated for pain. 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 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need a new partial. The Plan 
denied your request. The Plan says your benefits for this service have been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to one partial denture 
every 5 years. The record shows that you received a maxillary partial denture (D5213) on March 5, 2021 and 
your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a maxillary partial denture (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the test for detecting genes associated with prostate 
cancer in urine (0005U). 
 
You asked the Plan to pre-approve prostate cancer genetic testing. You say that this genetic testing service is 
medically necessary. 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 biomarker testing for prostate cancer is not 
covered when PSA is greater than 10 ng/mL.  
 
We looked at the file and Medicare rules. In this case, the enrollees PSA has been confirmed to be 12.3 
ng/mL. Since this is greater than 10 ng/mL, this request will not be covered. Based on this information, we 
decided that Medicare rules for coverage of prostate cancer genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the test for detecting genes associated with prostate cancer 
in urine (0005U).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The 
Plan denied your request. The Plan says LTACH is not medically necessary and continued acute hospital stay 
was offered, until the enrollee could discharge to a lower level of 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 there is no documentation provided indicating the medical necessity for LTACH 
services. Our physician reviewer found that the enrollee is receiving appropriate care at her current hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 the SNF 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 based on the documentation provided the enrollee only requires 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. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs).
You asked the Plan to pre-approve RFAs. You say that you are in a lot of pain but got relief from medial
branch blocks. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because you did not have at least 80% pain relief from the original diagnostic facet joint injections.
The Plan follows Medicare rules. Medicare rules state that therapeutic facet joint interventions such as
radiofrequency ablations (RFAs) may be covered if certain criteria are met.
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 RFAs. Our reviewer says that you do
not meet the Medicare criteria for the requested radiofrequency ablations (RFAs). Our physician reviewer
found not enough pain relief was reported after your first series of facet injections.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of RFAs have not been met. Therefore, we decided that the Plan does not have to
pre-approve radiofrequency ablations (RFAs).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
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 based on the documentation provided the enrollee only requires 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. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH)
services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neck brace (L0174), provided on October 11, 2021.

You asked the Plan to pay for the neck brace. You say that the service is medically necessary. The Plan denied
your request. The Plan says this item was obtained through an unsolicited telephone call.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the neck brace have
not been met. Therefore, we decided that the Plan does not have to pay for the neck brace (L0174), provided on
October 11, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the venography (75820). We decided that the Plan does not have to pay 
for the transcatheter placement of intravascular stent (37239).  
 
You asked the Plan to pay for the transcatheter placement of intravascular stent (37239) and venography 
(75820). You say that the enclosed medical records support the denied codes and payment for the procedures 
should be reconsidered. The Plan says that CPT code 37239 is not supported by the medical records and CPT 
code 75820 is considered inclusive to CPT code 37238. 
 
We decided that the Plan has to pay for the venography (75820).  
 
Our reviewer says that the documentation meets the criteria for coverage for the venography (75820). Our 
reviewer found that the procedure report supports the venography as a diagnostic procedure. Therefore, we 
decided that the Plan has to pay for the venography (75820).  
 
We also decided that the Plan does not have to pay for the transcatheter placement of intravascular stent 
(37239). 
 
Our reviewer says that the documentation does not meet the criteria for coverage of CPT code 37239. Our 
reviewer found that this procedure was not found in the procedure report and cannot be verified. Therefore, we 
decided that the Plan does not have to pay for the transcatheter placement of intravascular stent (37239). 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 based on the documentation provided, you do not require the intensity of services 
provided at an IRF. Specifically, you have not been shown to require fifteen hours per week of rehabilitative 
services and regular physician evaluation. Your care needs can be met 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.