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

 
We decided that the Plan does not have to pre-approve IRF care, from November 23, 2020, forward. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does 
not support that you require at least three (3) hours a day / five (5) days a week, or fifteen (15) hours over seven 
(7) consecutive days, of therapy 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF care, from November 23, 2020, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 12, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 80307 and HCPCS G0483 are not supported in the medical record. Specifically, the 
place of service on the CMS-1500 form must reflect the location of the patient when the specimen was 
obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of 
place of service of a doctor's office (POS 11) Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing services provided to the enrollee on February 12, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve extracorporeal photopheresis (CPT 36522) provided to the 
enrollee on June 25, 2020. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found chronic 
allograft rejection remains a major cause of morbidity and mortality following lung transplantation. There are 
two types and this patient has Bronchiolitis obliterans syndrome (BOS) and has failed prior therapies. 
Extracorporeal psoralen photopheresis (ECP) in the setting of BOS suggest that it reduces the rate of decline in 
lung function. Those who responded to ECP had better survival and a lower rate of retransplantation than 
nonresponders. The service was reasonable and 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 services have been met. Therefore, we decided that the Plan has to pre-
approve extracorporeal photopheresis (CPT 36522) provided to the enrollee on June 25, 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: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for laboratory services provided. 
 
You asked the Plan to hold you harmless for the laboratory services. You say that you would like 
reconsideration because these services were ordered by your physician and you were not aware that they would 
not be covered. The Plan denied your request. The Plan says that these services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for laboratory services provided.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romosozumab-appg (Evenity). 
 
You asked the Plan to pre-approve Romosozumab-appg (Evenity). You say that the medication is necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Romosozumab-appg (Evenity). Our 
reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation 
does not support a history previous treatment, contraindication, or intolerance to Fosamax and Actonel. Step 
therapy, as outlined by the plan, requires these medications be trialed or documentation rationale for not 
trialing them.  
 
 
Without the support of the documentation, Romosozumab-appg (Evenity) is not approved as step criteria is not 
met. Additionally, review of Medicare approved compendia notes the requested medication is FDA approved 
for post-menopausal osteoporosis. The literature does not support the use in men. Medical necessity cannot be 
determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Romosozumab-appg (Evenity) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Romosozumab-appg (Evenity).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat medial branch block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says no relief was obtained from the initial medial branch block. 
 
The Plan must follow Medicare rules. Medicare rules say that a second confirmatory medial branch block 
(MBB) is allowed if documentation indicates the first MBB produced significant relief of primary (index) pain 
of 50% or more.  
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found on July 20, 2020, the enrollee had a medial branch nerve block on L4-5 and L5-S1. The enrollee failed to 
obtain any documented relief from these procedures. A repeat procedure is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a repeat medial branch block for the enrollee.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different 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 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 the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in an intensive rehabilitation therapy program. 

 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the preventive procedure (D1999) provided on July 7, 
2020. 
 
You asked the Plan to pay for the preventive procedure. You say that prior to this appointment, you contacted 
the Plan in search of a contracted provider. You also say that at the appointment you were assured that your 
insurance would cover the services. The Plan denied your request. The Plan says this service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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. The Plan paid $10.00 for this service, but you are still responsible for 
the additional $5.00 charge because this service is not a covered benefit. Therefore, we decided that the Plan 
does not have to pay more for the preventive procedure (D1999) provided on July 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 74176) provided to the enrollee on 
April 22, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier is needed to represent the services as distinct and unique. 
 
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, we have confirmed that CPT code 
74176 has a bundled relationship with CPT code 74177 and cannot be paid as billed. This code cannot be paid 
as a separate line item, without the appropriate modifier appended. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology 
services (CPT 74176) provided to the enrollee on April 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February 
6, 2020, to March 4, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 home health services 
provided to the enrollee from February 6, 2020, to March 4, 2020.
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 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 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 medically necessary. Our physician reviewer found the records show that 
you were admitted to the hospital with a spinal cord injury, heart attack, and respiratory failure. You underwent 
spine surgery and received a feeding tube and pacemaker. You are on a ventilator and require additional short 
term acute services, which are available at the current hospital. You do not require any services that are not 
currently available at the hospital. The LTACH 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services received on July 1, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services received are not a covered benefit. 
 
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. Review of the file shows that a claim was not submitted with the case file. In 
addition, the plan did not identify that the services were received by an out of network provider or whether the 
services were referred to you by a network provider. The case file also does not specify why these services are 
being denied. Therefore, we decided that the Plan has to pay for the laboratory services received on July 1, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high flow oxygen concentrator for the enrollee. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the plan does not cover duplicate or redundant DME. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The rules say Medicare covers DME only when it is reasonable and necessary. If 
DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable 
and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
is requesting a second high-flow oxygen concentrator due splitting time between two homes. She is on oxygen 
at night and with exertion, and supplemental oxygen is medically necessary. However, Medicare does not 
cover duplicate durable medical equipment. A second oxygen concentrator would be considered a convenience 
item, and therefore 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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high flow oxygen concentrator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the eye injections and ER visit provided 
from January 13, 2020 through July 21, 2020. 
 
You asked the Plan to waive the copayment for the eye injections and ER visit. You say that you were never 
informed you had a copayment. The Plan denied your request. The Plan says the copayments 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 $150 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges and a $90 copayment for 
each emergency room visit.  


You have been asked to pay a total of $840 for the eye injections and ER visit.  
 
Date of Service Service Standard Copayment Member Liability 
January 13, 2020 Eye Injection $150 $150 
February 7, 2020 Eye Injection $150 $150 
May 6, 2020 ER Visit $90 $90 
May 11, 2020 Eye Injection $150 $150 
June 16, 2020 Eye Injection $150 $150 
July 21, 2020 Eye Injection $150 $150 
TOTAL:   $840 
 
The eye injections fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The ER visit falls within the 
Emergency Care 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 eye injections 
and ER visit provided from January 13, 2020 through July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the CT Angiography (CTA) provided. 
 
You asked the Plan to waive the cost share for the CTA. 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 a CTA on the date of service at issue in this appeal. The Plan says that the 
correct cost share 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. Your 
contract with the Plan says that there is $300 deductible that must be paid before the Plan will pay their share 
for Outpatient diagnostic services, and a $150 copayment once the deductible has been met.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category Outpatient 
diagnostic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$300 deductible before the Plan will pay their share for Outpatient diagnostic services. This cost sharing is a 
contractual obligation that had been met at the time the CTA was received. You are responsible 
for the remainder of your deductible per the contract with the Plan and as you met your deductible on the date 
of service at issue, a copayment also applied. Therefore, we decided that the Plan does not have to waive the 
cost share for the CT Angiography (CTA) provided.  
 
 
 
 
 
 
 
 
Your complaint about the technician not providing adequate instructions is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray and bitewings 
provided on June 22, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray and bitewings. You say that you were 
told these services were covered twice per year. The Plan denied your request. The Plan says the benefits for 
these services have been satisfied and the frequency limitations have been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on June 22, 
2020, and your intraoral x-rays benefit has been exhausted. Bitewing x-rays are also listed as a covered benefit 
and are limited to one set per calendar year. The record shows that you received bitewing x-rays on January 20, 
2020, and your bitewing x-ray benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pay for the additional intraoral periapical x-ray and bitewings provided on June 22, 2020.