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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot move around or transport anything. You 
say that you have trouble getting anything in the door ways because they are small. The Plan denied your 
request. The Plan says an IRF admission 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 that the complexity of your nursing, medical and rehabilitation can be provided in a 
lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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: 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 say that you disagree with the denial for the 
admission to a post-acute inpatient rehabilitation facility. The Plan denied your request. The Plan says the 
required services for the enrollee can be provided in an alternate setting.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies. There is documentation that there 
is a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 meets full IRF criteria and requires 
intensive inpatient rehabilitation with daily physician management, continuous specialized rehabilitation 
nursing, and intensive therapies to optimize mobility and strength while ensuring the restoration of functional 
status for a safe and sustainable discharge. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements for admission to an IRF. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the enrollees condition in fact remains complex and fragile, despite having spent 2 weeks in a 
skilled nursing facility, and there is every reason to expect that they will participate in and benefit from services 
to include at minimum physical therapy, occupational therapy, respiratory therapy, a nutritionist, physician 
oversight of polypharmacy, and case manager coordination of any additional services that might be needed to 
make a sustainable return home as well as avoid preventable readmissions to the acute 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that 83-129; 137-212; 235-282; 290-365 The Plan denied 
your request. The Plan says the request for an IRF admission does not meet medical necessity 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The enrollees condition is in fact complex and fragile, and there is every reason to expect that they 
will participate in and benefit from services to include at minimum physical therapy, occupational therapy, 
physician oversight of post-operative risks and polypharmacy, and case manager coordination of any additional 
services that might be needed to make a sustainable return home, as well as avoid preventable readmissions to 
the acute 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391), 
and resin-based composite - two surfaces, posterior (D2392) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial and would like the 
plan to reconsider payment. The Plan denied your request. The Plan says these services are not covered by the 
plan. 
 
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 pay for the resin-based composite - one surface, posterior 
(D2391), and resin-based composite - two surfaces, posterior (D2392) provided on April 12, 2022.
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 this care. The Plan 
denied your request. The Plan says medical records do not show that the enrollee must have an intensive 
therapy program and services can be provided 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. Our 
physician reviewer found the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post-stabilization care provided from July 12, 2022, to 
July 29, 2022. 
 
You asked the Plan to pay for the post-stabilization care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says all emergent care to the point of stability has been 
paid. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our reviewer says 
that the post-stabilization care was not medically necessary at the out-of-network hospital. Our physician 
reviewer found that there was no documentation where the treating physician documented the enrollee as not 
stable for transfer to an in-network 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 post-stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post-stabilization care provided from July 12, 2022, to July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on May 19, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that you 
did not want to submit to Part D for reimbursement due to having a bad experience in the past. The Plan denied 
your request. The Plan says you were advised to submit the reimbursement under your Part D coverage, but 
you declined. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on May 19, 2023.
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 services are medically necessary. The 
Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require 
transfer to a LTACH. 
 
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 you do not require services at the LTACH that are not available at the acute care 
hospital. There are no services available at the LTACH that you require that are not available at the health care 
setting being offered by the health plan. Given there are offered alternatives, LTACH is 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the trabecular bone score provided on May 
19, 2023. 
 
You asked the Plan to waive the copayment for the trabecular bone score. You say that you were told the 
provider wanted this test done. 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 $40 
copayment for in-network outpatient diagnostic tests. 
 
You have been asked to pay a $40 copayment for the trabecular bone score. This item/service falls within the 
in-network outpatient diagnostic tests 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. However, since the allowed amount is less than the standard copayment, you 
only owe $39.15. Therefore, we decided that the Plan does not have to waive the copayment for the trabecular 
bone score provided on May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on October 2, 2022. 
 
You asked the Plan to pay for initial observation care (99220). The Plan denied your request. The Plan says the 
medical records submitted do not support medical decision making of high complexity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  In this case, the CPT Code Manual definition of code 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
We asked our coder 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 initial observation care (99220). Our reviewer says that 
procedure code 99220 is not supported. Our reviewer found the documentation does not support medical 
decision-making of a high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial observation care (99220) have not been met. Therefore, we decided that 
the Plan does not have to pay for initial observation care (99220) provided on October 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 13, 
2023, to March 31, 2023. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary so they should be 
covered. The Plan denied your request. The Plan says the enrollee did not require daily skilled nursing services 
during the dates of 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 pay for SNF care. Our reviewer says that that the 
enrollee no longer qualified for SNF coverage, and the services were not medically reasonable and necessary 
based on Medicare guidelines. Our physician reviewer found that the enrollee did not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee 
did not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a SNF setting. The enrollee was ambulating more than 100 feet. Daily skilled services are not shown to 
have been required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
The enrollees care needs were custodial and could, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 13, 2023, to March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 83789 for date of service June 14, 2023. 
 
You asked the Plan to pay for code 83789. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for code 83789 for date of service June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant body tooth #19 (D6010), implant supported 
abutment tooth #19 (D6056) and implant supported crown tooth #19 (D6058). 
 
You asked the Plan to pre-approve these dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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. The Plan covers these dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found a review of the documentation 
indicates that missing tooth #19 has been replaced by a pontic supported by abutment retainers on teeth #'s 18 and 20.  This current bridge appears functional. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve implant body tooth #19 (D6010), implant supported abutment tooth #19 (D6056) 
and implant supported crown tooth #19 (D6058).