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

 
We decided that the Plan does not have to pre-approve long term LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information the Plan has about the enrollee's condition, the enrollee does not meet 
the requirements for 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 based on the documentation provided, the health Plan?s denial of LTACH coverage 
should be upheld. The enrollee is currently undergoing treatment at an ACH following surgery to remove a 
brain tumor. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has 
been weaned to a tracheotomy mask. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing LTC needs. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a maxillofacial Computed Tomography (CT) scan. 
 
You asked the Plan to pre-approve CT scan. You say that a CT scan is indicated to assess for sinusitis. The 
Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this 
test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee 
presented for nasal congestion and difficulty breathing through the nose. He was diagnosed with chronic 
pansinusitis. The symptoms can include facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal 
obstruction. The enrollee has had 2 of these 4 symptoms for years. To fully diagnose chronic sinusitis, an 
objective examination such as nasal endoscopy and/or CT scan should be performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a maxillofacial Computed Tomography (CT) scan.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee 
and billed under code J9035.  
 
You asked the Plan to pay for code J9035. You say that this claim should be paid. The Plan denied your 
request. The Plan says HCPCS code, J7999, is a more appropriate code to bill for bevacizumab (Avastin) for 
off label ophthalmic use; therefore, the billed service cannot be verified. It is noted that multiple attempts were 
made to contact the provider for additional information. 
 
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, there is a more appropriate code 
that should be used to report this service. The Plan states a corrected claim would be reviewed if submitted. 
Medicare rules for coverage of code J9035 have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee and billed under code J9035.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on June 26, 2020, to July 1, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you would like this claim reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
these services were self-referred. 
 
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 has network providers 
available who can provide 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 chiropractic services provided on June 26, 2020, 
to July 1, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection, pegfilgrastim 6mg (J2505) and 
injection, aprepitant, 1 mg (J0185) provided. 
 
You asked the Plan to waive the copayment for injection, pegfilgrastim 6mg and injection, aprepitant, 1 mg. 
You say that you were unaware of the cost share and would not have received the services if told in advance. 
The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for injection, pegfilgrastim 6mg and injection, aprepitant, 1 
mg. injection, pegfilgrastim 6mg and injection, aprepitant, 1 mg 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 copayment for injection, pegfilgrastim 6mg 
(J2505) and injection, aprepitant, 1 mg (J0185) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on March 12, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that they used the wrong machine for the 
first MRI, so it didn't work. You say that you shouldn't be charged for the second test. 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 $175 
copayment for each Medicare-covered advanced radiology service.  
 
You have been asked to pay a $175 copayment for the MRI. The MRI falls within the "Outpatient diagnostic 
tests and therapeutic services and supplies" benefit category. The records show that the MRI was performed. 
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 MRI provided on March 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) 
you had at an ambulatory surgical center on July 31, 2020. 
 
You asked the Plan to waive the copayment for the EGD. You say that you have this procedure every 4-5 
years.  You say that this should be covered. The Plan denied your request. The Plan says this service was 
covered; however, you were assessed the appropriate copayment for this 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 $325 
copayment for visits to an ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for the EGD. the EGD falls within the visits to an ambulatory 
surgical center 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 the EGD you had at an 
ambulatory surgical center on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional days of inpatient psychiatric care. 
 
You asked the Plan to pre-approve the additional days of inpatient psychiatric care. You say that an inpatient 
level of care is medically necessary. The Plan denied your request. The Plan says the clinical information 
provided does not support the requested level of care. The Plan says that the enrollee can be treated in an 
outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 additional days of inpatient 
psychiatric care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer 
found the enrollee was admitted to the acute inpatient psychiatric hospitalization on December 3, 2020 with 
Major Neurocognitive Disorder with Behavioral Disturbance. Based upon review the records provided it was 
not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was 
not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive 
behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or 
 
 
abnormal behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in 
question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or 
visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did 
not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the patient?s condition or for the purpose of diagnosis. Based upon review the records provided, this 
patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of December 15, 2020 forward and could have been treated in a lesser restrictive 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 additional days of inpatient psychiatric care have not been met. Therefore, 
we decided that the Plan does not have to pre-approve additional days of inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external ambulatory infusion pump, insulin (CPT Code 
E0784), supplies for external insulin infusion pump, syringe type cartridge, sterile, each (A4225) and supplies 
for maintenance of insulin infusion catheter, per week (A4224). 
 
 
 
You asked the Plan to pre-approve the supplies. You say that the supplies are necessary. The Plan denied your 
request. The Plan says the notes show that the member meets most of the steps to get a pump; however, there is 
one step that does not meet the criteria to get the pump. 
 
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 supplies. Our physician reviewer 
found in order to meet criteria the member would need to have a c-peptide less than 0.88 which is 110% of the 
lower limit of normal. This is not the case so the member does not meet criteria. 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 supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve external 
ambulatory infusion pump, insulin (CPT Code E0784), supplies for external insulin infusion pump, syringe 
type cartridge, sterile, each (A4225) and supplies for maintenance of insulin infusion catheter, per week 
(A4224).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis services (90999) provided on 
June 15, 2020, to June 29, 2020. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you were unaware there 
would be a cost share associated with this service and would like the cost share waived. The Plan denied your 
request. The Plan says the coinsurance applied correctly in this case. 
 
 
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 services to treat kidney disease.  
 
You have been asked to pay a total cost share of $428.82 ($2144.10 allowed amount x 20% coinsurance). The 
services provided fall within the services to treat kidney disease 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 dialysis services (90999) provided on June 15, 2020, to June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 22, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says it is not 
appropriate to report left and right diagnosis codes when a more specific code is available. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the services at issue were not billed with the most 
comprehensive diagnosis code. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on 
June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has  for vision supply (V2797) provided on July 24, 2019. 
 
You asked the Plan  for vision supply. You say that you did not realize you sent the forms in late. The Plan 
denied your request. The Plan says that claims submitted more than 11 months (335 days) following the date of 
service are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers has a $100 allowance for prescription glasses (including prescription sunglasses) or 
contact lenses per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, there is no evidence you have exhausted your $100 
allowance for this service. Based on this information, we decided that the Plan's rules for coverage of vision 
supply have been met. Therefore, we decided that the Plan must pay the $100 allowance for vision supply 
(V2797) provided on July 24, 2019.  
 
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 long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided 
supports the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee does not 
meet the guidelines for long term acute care services. The Plan says that the enrollee can safely receive the 
services needed in the current hospital setting. 
 
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 is currently undergoing treatment at an acute care hospital (ACH) for 
CoViD-19.  The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires services 
that are not currently available. There is no advantage in transferring the enrollee to the LTACH.  The enrollee 
can remain at the current ACH until such a time that no acute services are required.  The enrollee can then be 
transferred/discharged to a lower level of care for any ongoing long-term care needs. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer Superion interspinous 
spacer (CPT Code 22869). 
 
You asked the Plan to pre-approve the service. You say that you are in a lot of pain and cannot sleep or do 
anything. The Plan denied your request. The Plan says your policy currently classifies the procedure as 
experimental and does not provide coverage for this service. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the 
spinal decompression device procedure over the ?gold standard? of lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for your medical 
condition as discussed above. FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. You have severe central canal stenosis at L4/5 which would not meet 
FDA indications. FDA contraindications include spinal instability, obesity, and osteoporosis. Superion indirect 
lumbar decompression would not be considered the standard of care for your medical condition. Therefore, this 
request does not meet Medicare criteria as medically reasonable and necessary for treatment of your medical 
condition. 
 
 
 
 
 
 
 
 
 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Superion interspinous spacer Superion interspinous spacer (CPT Code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee. 
 
You asked the Plan to pay for the orthosis. You say that  The Plan denied your request. The Plan says that 
documentation submitted did not indicate the provider discussed the need for the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the lumbar sacral orthosis provided to the enrollee.