Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee has skilled needs and should 
be approved for a SNF admission. The Plan denied your request. The Plan says that the request for a SNF 
admission is not deemed 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 meets the Medicare criteria for SNF care. Our physician reviewer found the enrollee has daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that the enrollee has daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that the 
enrollee requires daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve a 
skilled nursing facility (SNF) admission.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 25, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the testing was medically necessary and 
ordered by the enrollee's physician. The Plan denied your request. The Plan says the rendering and referring 
providers are both OON providers and there was no 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 the laboratory services provided on January 25, 
2022, by an 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services he needs 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of basal ganglia stroke, falls, cervical fracture and is living at home with ongoing weakness. The enrollees medical 
problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on March 1, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that it was medically necessary to treat the 
enrollee and you would like reconsideration of payment for the claim. The Plan denied your request. The Plan 
says the rendering provider is an OON 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 the outpatient office visit provided on March 1, 
2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine/Naloxone 8-2mg. 
 
You asked the Plan to pre-approve the Buprenorphine/Naloxone. You say that Buprenorphine/Naloxone is 
medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under 
the Part B medical benefit. 
 
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 Buprenorphine/Naloxone 8-
2mg.  
 Benefits for the Buprenorphine/Naloxone 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient hospital observation services and 
Part B Drugs provided on September 22, 2021, and September 29, 2021. 
 
You asked the Plan to waive the cost share for outpatient hospital observation services and Part B Drugs. You 
say that you believe the claim was processed incorrectly. The Plan denied your request. The Plan says the cost 
sharing amount was 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  $295 
copayment for Outpatient Hospital Observation Services and 20% coinsurance for Medicare Part B drugs 
when, at an outpatient hospital. 
 
You have been asked to pay a  total of $2,449.40 for outpatient hospital observation services and Part B Drugs.  
 
Date of Service Service Allowed 
Amount 
Standard Cost Member Liability 
September 22, 2021 Medicare Part B drugs $4,648.49 20% $929.70 
September 22, 2021 Intravenous Infusion $566.64 $295 $295 
September 29, 2021 Medicare Part B drugs $4,648.49 20% $929.70 
September 29, 2021 Intravenous Infusion $566.64 $295 $295 
TOTAL:    $2,449.40 
 
Outpatient hospital observation services and Part B Drugs fall within the Outpatient hospital 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 cost share for outpatient hospital observation services and Part 
B Drugs provided on September 22, 2021, and September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode 
array, epidural (63650) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records show the enrollee has not had maximal medical 
management. 
 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The records do not 
records show that the enrollee has a condition that is indicated for coverage. Detailed documentation is not 
evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care 
measures. There is not clear documentation of any recent physical therapy, medication usage or injection trial 
and failure. There is no indication that she has been evaluated by a multidisciplinary team. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Percutaneous implantation of neurostimulator electrode array, epidural (63650) for the 
enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS trial. You say that it is felt that this should be allowed due to failure 
of other treatments. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SCS stimulation may be considered for intractable 
pain as a late, if not last, resort.  
 
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 SCS trial. Our reviewer says that 
the requested SCS is not considered to be medically necessary at this time. Our physician reviewer found this 
51-year-old male enrollee has post-herpetic neuralgia of the thoracic region. He takes oxycodone and 
gabapentin. Topical medications have not been tried (e.g., Lidoderm). The enrollee is not taking the maximal 
dosage of gabapentin and has no documented trial of epidural steroid injections.   
There are several therapies that this patient has not tried and therefore, this is not a late, or last resort. The 
request at this point is not medically reasonable or necessary. 
 
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 SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve placement of a spinal cord stimulator (SCS).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found detailed documentation 
is not evident regarding significant recent symptom worsening or deterioration of neurologic findings. There 
are no objective clinical findings of myotomal weakness, reflex loss, or dermatomal sensory deficits. The 
provided documentation does not include any lumbar exam findings. There are no x-rays of the lumbar spine 
provided for review. Additionally, detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures. There are limited large-scale, long-
term references showing the medical necessity of the requested study in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested lumbar MRI, in this case, is not medically reasonable or 
necessary. 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health physical therapy provided on February 11, 2021, through 
February 25, 2021. 
 
You asked the Plan to pay for the home health physical therapy. You say that you would like reconsideration 
because the provider does not partner with the primary insurance. The Plan denied your request. The Plan says 
that an explanation of benefits from your primary insurance carrier is required. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not 
forwarded evidence that they have sent the bill directly to the primary insurer for payment, directed the 
provider to send the bill to the primary insurer or paid for the services and submitted a bill for reimbursement 
to the primary insurer.  It is the burden of the Health Plan to substantiate their denial with evidence. In this case 
the Plan has not provided evidence that they have met their coordination of benefits obligation. Therefore, we 
decided that the Plan has to pay for home health physical therapy provided on February 11, 2021, through 
February 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient services provided on 
January 14, 2022. 
 
You asked the Plan to waive the coinsurance for the outpatient services. The Plan denied your request. The 
Plan says to have services covered from an out-of-network provider at the in-network benefit level, you must 
first get an approved prior authorization before services are rendered. We have confirmed that no prior 
authorization was obtained prior to services being rendered. 
 
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 20% 
coinsurance for outpatient hospital services.  
 
You have been asked to pay $62.92 for the outpatient services. The outpatient services falls within the outpatient hospital 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 coinsurance for outpatient 
services provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 15, 2020, to 
November 18, 2020, as billed with Diagnosis Related Group (DRG) 871. 
 
 
 You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not 
supported as the diagnoses of sepsis, unspecified organism (A41.9), severe sepsis without septic shock 
(R65.20) and acute respiratory failure with hypoxia (J96.01) are not supported in the medical record. The Plan 
argues that DRG 194 is more appropriate in this case. 
 
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.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care billed with DRG 871. Our 
reviewer says that the diagnoses of sepsis, unspecified organism (A41.9), severe sepsis without septic shock 
(R65.20) and acute respiratory failure with hypoxia (J96.01) are not supported in the medical record for this 
inpatient admission. Our physician reviewer found that the enrollee presented with shortness of breath with 
associated cough and was diagnosed with chronic obstructive pulmonary disease (COPD) exacerbation and 
pneumonia. The record indicates that the enrollee had hypotension with mean arterial pressures of less than 70. 
The enrollee did not require vasopressor use for her hypotension. Per the provider in the history and physical, 
"HTN-resume home meds as tolerated. Adjust as needed". When the enrollee presented on November 15, 2020, 
her creatinine was noted to be 1.3. The care timeline indicates that by November 16, 2020, at 12:25AM, the 
enrollees creatinine had trended down to 1.16. The laboratory reports indicate that the enrollees platelet count 
remained above 150,000, total bilirubin remained below 1.2. The enrollees output was not reported 
consistently but was not noted to be clinically significant during this admission by the provider. The enrollee 
was noted to be alert and oriented during this admission. There was no clinical or laboratory evidence of sepsis. 
The review has determined that the medical records did not support the billing of sepsis, unspecified organism 
(A41.9), severe sepsis without septic shock (R65.20) and acute respiratory failure with hypoxia (J96.01). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from November 15, 2020, to November 
18, 2020, as billed with Diagnosis Related Group (DRG) 871.