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

 
We decided that the Plan does not have to pre-approve inpatient stay. 
 
You asked the Plan to pre-approve inpatient stay. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 inpatient stay. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee appeared stable and although required surgical correction of her arm fractures, was 
no exhibiting any signs of acute coronary syndrome or other condition which warranted admission status. 
Although troponin was slightly elevated, in the setting of no clinical correlation with this and a history of 
hypertrophic obstructive cardiomyopathy and recent injury which would suggest no need for treatment. This 
clinical presentation would not warrant inpatient status which would be not medically necessary, but 
observation status would have been most appropriate for short-term blood testing and monitoring and 
coordinating outpatient care. Therefore, the enrollee does not meet criteria for the requested 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 inpatient stay have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office outpatient visit (99214) provided on January 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services by an out-of-network providers.
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 the office outpatient visit (99214) provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on February 4, 2020.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lab services provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests (87150, 87481, 87491, 87500, 87591, 87640, 87641, 
87653, 87661, 87798) provided February 4, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these tests are not covered as screening tests. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these 
tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab tests 
(87150, 87481, 87491, 87500, 87591, 87640, 87641, 87653, 87661, 87798) provided February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on February 15, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 15, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 spinal fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found criteria for spinal fusion has been not met. There is no clearly documented spinal 
instability, fracture or lesion. There is no severe neurologic deficit documented. Fusion surgery is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of varicose veins. 
 
You asked the Plan to pre-approve radiofrequency ablation of varicose veins. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation of varicose veins is only 
covered for certain indications. 
 
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 radiofrequency ablation of varicose 
veins. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has varicose veins of bilateral lower 
extremities with pain and generalized edema. It is documented that the enrollee has significant vascular 
stenosis in his bilateral lower extremities. The enrollee has a large right leg ulcer with heavy drainage. It is 
documented that the enrollee has Atherosclerosis of the native arteries of his bilateral lower extremities with 
intermittent claudication. The documentation does not support that the enrollee has a diagnosis, condition, 
and/or symptoms that meet the Medicare criteria for coverage of radiofrequency ablation of varicose veins. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of varicose veins have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of varicose veins.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 above. 
 
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 medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on September 29, 2020 and discharged to a skilled nursing facility on October 7, 2020. 
The IRF screen on October 8, 2020 states you need assistance with transfers, eating, and toileting. The records 
do not show that you require the intensity of services in an IRF. Specifically, you do not require 15 hours per 
week of rehabilitative services and regular physician evaluation. The IRF services are not reasonable or 
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 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 endovenous ablation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that not having the procedure will endanger 
the enrollee's health. The Plan denied your request. The Plan says the enrollee has a weak blood supply in the 
legs. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation are only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has numerous cardiovascular risk factors. He has known, significant arterial 
occlusive disease (PAD) in the lower extremities bilaterally with documented severe claudication and 
documented rest pain. Coverage criteria requires documentation of the absence of significant peripheral artery 
disease. Therefore, the requested services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapeutic phlebotomy (99195) and non-
invasive pulse oximetry (94760) provided January 2, 2020 to January 23, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that these services 
were covered before The Plan denied your request. The Plan says the claim has processed correctly and the 
correct copayment was applied. Since the copayment was higher than the allowed amount you are being asked 
to pay the lesser amount of $110.73. 
 
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 $250 
copayment per visit for outpatient surgery or procedure for Outpatient hospital services.  
 
You have been asked to pay $110.73. Since the copayment was higher than the allowed amount you are being 
asked to pay the lesser amount of $110.73 for the outpatient hospital services. The outpatient hospital services 
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 copayment for therapeutic phlebotomy (99195) and non-
invasive pulse oximetry (94760) provided January 2, 2020 to January 23, 2020.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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 available records, the patient does not meet CMS coverage criteria for an 
IRF admission. The patient has no medical complexity for an IRF admission. The patient is medically stable 
with spinal stenosis. Status post-surgery and wound infection. Stable with intravenous (IV) antibiotics to be 
given for a total of eight (8) weeks with slow progress in physical therapy (PT) and occupational therapy (OT). 
There is no evidence of need for supervision by Physical Medicine and Rehabilitation (PM&R) physician three 
(3) times a week or needing acute rehab nursing care. The documentation does not support that there is a need 
for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. The 
patient still needs a lot of assistance due to thoracic-lumbar-sacral orthosis (TLSO) and will need prolonged 
therapies due to slow progress that are not appropriate in an IRF. The patient can be safely transitioned to a 
skilled nursing facility (SNF) rehab. IRF admission 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a thigh fracture treatment 
(27245) provided by a registered nurse first assistant (RNFA) on February 15, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this provider is not covered. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a thigh 
fracture treatment (27245) provided by a registered nurse first assistant (RNFA) on February 15, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the additional 120 units of Formoterol fumarate (J7606-KO) billed for 
date of service March 30, 2020. 
 
You asked the Plan to pay for the additional 120 units of Formoterol fumarate. You say that the claim denied in 
error. The Plan denied your request. The Plan says that they only paid for 60 units of the drugs because only 
one date of service was billed. The Plan says that it appears the claim was billed for a 90-day supply, but that 
only one date of service was billed for the drug. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not shown any reason why a 90-day supply of the 
billed drug is not payable for this claim. We found no Medicare rule that says that a 90-day range of dates is 
required on a claim in order to report a 90-day supply. The Plan has not supported their denial reason. 
Therefore, we decided that the Plan has to pay for the additional 120 units of Formoterol fumarate (J7606-KO) 
billed for date of service March 30, 2020.  
 
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 pay for the inpatient hospital services provided from March 17, 2020 to March 
28, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the inpatient hospital services 
provided were not medically necessary. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan is denying payment for the inpatient hospital services 
provided from March 17, 2020 to March 28, 2020 as not medically necessary. However, the Plan did not 
provide any of the medical records for review to substantiate a denial for lack of medical necessity. Therefore, 
we decided that the Plan has to pay for the inpatient hospital services provided from March 17, 2020 to March 
28, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 22, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the urgent care visit provided on February 7, 
2020. 
 
You asked the Plan to waive the cost share for the urgent care visit. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received an urgent care visit on the date of service at issue in this appeal. The 
Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $10 
copayment for Urgently needed services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an urgent care 
visit on February 7, 2020. You have been asked to pay a $10 copayment for the urgent care visit. The urgent 
care visit falls within the Urgently needed 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 urgent care visit provided on February 7, 2020.