Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not show any clinically significant status changes, new medical concerns or changes in 
medication/treatment plan thus further home health palliative skilled nursing services are not medically 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 19, 2022, to December 23, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware of 
the copayment for inpatient hospital care. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $175 
copayment per day for days 1-7 of each inpatient hospital stay. Your contract with the Plan also says that you then must pay a $0 copayment per day for days 8-90 of the same inpatient hospital stay. 
 
You have been asked to pay a $175 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged for the day you 
were discharged. You have been asked to pay a total of $700 ($175 copayment per day x 4 days = $700). 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 inpatient hospital stay provided from December 19, 
2022, to December 23, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 29, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on November 29, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on October 10, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient mental 
health visit provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits, x-ray, walking 
boot, and surgical services provided from January 4, 2023, to January 25, 2023. 
 You asked the Plan to waive the cost share for the specialist office visits, x-ray, walking boot, and surgical 
services. You say that you made a copayment on the dates of service and should not owe more. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $25 
copayment for each in-network specialist office visit. Your contract with the Plan also says that you must pay a 
$30 copayment for each in-network x-ray provided at an outpatient hospital facility. Your contract with the 
Plan also says that you must pay 20% coinsurance for in-network durable medical equipment and related 
supplies. Your contract with the Plan also says that you must pay a $245 copayment for in-network surgical 
services provided at an outpatient hospital facility. 
 
Date of Service CPT code Allowed Amount Copayment Coinsurance 
January 4, 2023 73630 $84.85 $35 - 
January 4, 2023 L4361 $205.02 - $41.01 
January 4, 2023 99203 $79.86 $25 - 
January 25, 2023 99213 $66.32 $25 - 
January 25, 2023 G0463 $118.04 $118.04 - 
Total $244.05 
 
You have been asked to pay a $25 copayment for each specialist office visits. This item/service falls within the 
physician/practitioner services benefit category. You also have been asked to pay a $35 copayment for the x-
ray. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit category. You 
have also been asked to pay 20% coinsurance for the walking boot. This item/service falls within the durable 
medical equipment and related supplies benefit category. You have also been asked to pay $118.04, which is 
less than the standard $245 copayment for the surgical services. This item/service 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 cost share for the specialist office visits, x-ray, walking boot, and surgical 
services provided from January 4, 2023, to January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical access to implant body (D6011) for tooth #3 
provided on February 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are requesting the Plan to authorize the 
remaining payment to complete your dental procedure. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already 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, certain limitations apply. The record 
shows that the Plan paid for 2 surgical access to implant body (D6011) for tooth #4 and #10 on February 14, 
2023; therefore, your benefit for the requested item or service was exhausted on the date of service of February 
14, 2023. Therefore, we decided that the Plan does not have to pay for the surgical access to implant body 
(D6011) for tooth #3 provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a hospital evaluation and management (E&M) visit provided by a 
nonphysician practitioner on January 6, 2023. 
 
You asked the Plan to pay for hospital E&M visit. You say that the provider had an active role in the treatment 
of the enrollee. The Plan denied your request. The Plan says that this service is bundled into service code 99291 
paid billed on the same date by a provider in the same group practice. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules say that physicians of the same specialty and group practice must bill and be paid as though 
they were a single physician. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment on the basis that physicians of the same specialty and 
group practice must bill E&M services together, however, the provider at issue in this case is a Physician 
Assistant (PA) which is a nonphysician practitioner. Therefore, this Medicare rule does not apply to the billing 
and payment of this claim. The Plan has provided no other rationale or evidence to support a denial of payment 
for this claim. Therefore, we decided that the Plan has to pay for a hospital evaluation and management (E&M) 
visit provided by a nonphysician practitioner on January 6, 2023.  
 
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for myocardial infarction and coronary artery bypass grafting. Medical problems are stable. There 
are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient therapies to 
optimize mobility and strengthening while ensuring the restoration of functional status for a safe and 
sustainable discharge. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met in an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified adjunctive procedure (D9999). 
 
You asked the Plan to pre-approve laser surgery. You say that you have periodontal disease and need the laser 
surgery approved. The Plan denied your request. The Plan says this is not a covered service under your dental 
benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified adjunctive procedure (D9999).
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 therapy in order to 
reach full potential. The Plan denied your request. The Plan says the IRF services you are requesting do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 pre-approve Proton Beam Therapy (PBT) with 26 fractions (77520, 
77014, 77522, 77523, 77525, 77387, 77470, 55874, 77370, 77331). 
 
You asked the Plan to pre-approve PBT with 26 fractions. You say that the treatment is medically necessary 
and urgent. The Plan denied your request. The Plan says not all criteria have been met in this case. There is not 
enough medical evidence to show that this type of radiation treatment is more effective or has less side effects 
than other forms of radiation therapy for prostate cancer. 
 
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 PBT with 26 fractions. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. The bottom line is that proton therapy for prostate cancer is not 
experimental, and in fact is an accepted treatment approach. While our reviewer does not think that proton 
therapy is an experimental therapy, any potential benefit or detriment of proton therapy over standard IMRT is 
an investigational question. Notably, registry studies are not clinical trials or studies, and have a much less 
rigorous development process. A tumor registry does not address a specific scientific question but rather 
registers the enrollees clinical and treatment information into a database for potential analysis in the future. 
While ASTRO advocates for insurer coverage for enrollees enrolled on multi-institutional registries, ultimately 
this criterion does not establish medical necessity and is controversial. Nevertheless, it is not specified if a 
clinical trial review was sought or whether this insurer allows for clinical trial exceptions. The decision is 
unfavorable as the LCD criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT with 26 fractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Proton Beam Therapy (PBT) with 26 fractions (77520, 77014, 77522, 77523, 
77525, 77387, 77470, 55874, 77370, 77331).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve Feraheme. You say that the medication is a part of a treatment. The Plan 
denied your request. The Plan says  the step-therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically necessary. Our physician reviewer found that the documentation does not show a 
trial and failure of the requested drugs Ferrlecit, Infed Venofer. While you have been diagnosed with iron 
deficiency anemia secondary to blood loss, the documentation does not support that the required drugs would 
likely be less effective, and or would likely have adverse effects for you 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service June 19, 
2022, to July 18, 2022. You asked the Plan to pay for the billed services. You say that the codes are valid and billable. The Plan denied 
your request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 19, 2022. The NOA was not received by the Plan until December 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service June 19, 2022, to July 18, 2022.