Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on January 31, 2020, through 
May 1, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because 
the chiropractic services are medically necessary and should be covered. The Plan denied your request. The 
Plan says coverage only extends to manual manipulation of the spine. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rule 
also say that Medicare covers is manual manipulation of the spine to correct a subluxation. 
 
We find that the chiropractic services are not supported in the record. Specifically, coverage only extends to 
manual manipulation of the spine. Additionally, the provider has not reported these services appropriately. 
Based on this information, we decided that Medicare rules for coverage of the chiropractic services have not 
been met. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on 
January 31, 2020, through May 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from December 31, 
2019, to January 4, 2020. 
 
You asked the Plan to pay for the inpatient hospital services on December 31, 2019 and January 4, 2020. You 
say that the enrollee was not enrolled in hospice until they were discharged from the hospital. The Plan denied 
your request. The Plan says The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice 
care from the effective date of election to the date of discharge or revocation. The Plan also says that during the 
election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal 
illness until the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for December 31, 2019 and January 4, 2020.
 
Additionally, since hospice was discontinued on December 31, 2020, coverage beginning with the Medicare 
Advantage plan would have started on January 1, 2020. Because the enrollment change occurred during the 
enrollee's inpatient stay, Original Medicare would be responsible for the inpatient stay from January 1, 2020 to 
January 3, 2020 as well. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services provided from December 31, 2019, to January 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of Opdivo. 
The Plan denied your request. The Plan says the claims for routine costs associated with this clinical trial are 
not payable by the member's Plan. The Plan states you should submit claims to the Original Medicare 
contractor for the member's state which can be located by searching on the CMS website. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medication have not been met. The claim payment for managed 
care plan members for the covered routine costs associated with a clinical trial is the responsibility of the 
original Medicare contractor, and not the managed care plan. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo (J9299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 review indicates that there is no documentation provided requiring admission to a 
LTACH. The member's current needs are being met in the acute setting. The review has determined that the 
member does not require services at the LTACH that are not available at the acute care hospital where the 
member is currently receiving care. There are no services available at the LTACH that the member requires 
that are not available at the health care setting being offered by the health plan. The requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the member and 
able to be furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Purewick external catheter system. 
 
You asked the Plan to pay for a Purewick external catheter system. You say that you are now in the hospital for 
the fourth time within two months. You say that you will be released shortly and need the item approved. You 
say that you are not mobile and that you have MS. You say that it is hard for you to get around on your own. 
The Plan denied your request. The Plan says the item in dispute is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that PDAC determinations are evidence of the correct 
coding of an item. 
 
We looked at the file and Medicare rules. The item being requested carries a code of A9270, which is a 
noncovered item/service. Therefore, we decided that the Plan does not have to pay for a Purewick external 
catheter system.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subconjunctival injection (CPT Code 68200) provided on November 
22, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 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 services. Our physician reviewer found 
there was the statement of anesthesia locally provided and it is reasonably that the subconjunctival injection 
was the anesthesia applied. Our physician reviewer does not feel that it not being stated specifically as a reason 
to uphold the denial of a procedure that is likely to have been done. Our physician reviewer feels that the 
procedure performed and should be reimbursed. 
 
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 pay for 
subconjunctival injection (CPT Code 68200) provided on November 22, 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 walk-in bathtub (E1399). 
 
You asked the Plan to pre-approve the bathtub. You say that the tub is medically necessary. The Plan denied 
your request. The Plan says the tub is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from January 29, 
2020 to February 2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 inpatient hospital care on the dates 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 $225 
copayment per day for days 1-8 for Inpatient hospital care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient 
hospital care from January 29, 2020 to February 2, 2020. You have been asked to pay a $225 copayment per 
day for days 1-4 for the inpatient hospital stay, totaling $900. The inpatient hospital stay falls within the 
Inpatient hospital 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 inpatient 
hospital stay from January 29, 2020 to February 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the initial 15 minutes of deep sedation (D9222), an 
additional 15 minutes of deep sedation (D9223 x 2), a therapeutic drug injection (D9612), and a radical 
excision (D7410). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. You also say that 
your health is being affected. The Plan denied your request. The Plan says deep sedation is not listed as a 
covered service. The Plan says therapeutic drug injection is not listed as a covered service. The Plan says 
radical excision is not listed as a covered service either. The Plan also says if a dental item or service is not 
listed in the benefit chart or listed with NC, then it is not covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the 
initial 15 minutes of deep sedation (D9222), an additional 15 minutes of deep sedation (D9223 x 2), a 
therapeutic drug injection (D9612), and a radical excision (D7410).
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 level of care to 
help with transition back to the community. The Plan denied your request. The Plan says IRF criteria are not 
met in this case. 
 
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 enrollee had an elective total hip replacement on 11/3/2020 in the setting of 
chronic traumatic brain injury and seizure disorder. The complexity of the patient's nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient's medical status does not currently require intensive physician and nursing 
oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational 
therapy but the documentation does not support that the patient's functional status requires an intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi for the enrollee. 
 
You asked the Plan to pre-approve Imfinzi. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records provided do not indicate imaging results to confirm no potential 
progression on recent therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi. Our reviewer says that Imfinzi 
is not medically reasonable and necessary for the enrollee in this case. Imfinzi is FDA-approved for the 
enrollee's diagnosis as long as no progression after platinum based therapy with radiation. No follow-up 
imaging has been supplied. The documentation does not support that Imfinzi is safe and effective and otherwise 
reasonable and necessary for this enrollee as there is no imaging to show at least stable disease after 
chemotherapy with radiation. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of Imfinzi. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from April 22, 2020, to April 23, 
2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer. 
 
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 inpatient care. Our reviewer says that the 
requested inpatient care was post-stabilization care. Our physician reviewer found that the clinical 
documentation supports that the enrollee was stable for transfer to an in-plan hospital at 5:44pm on April 22, 
2020. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from April 22, 2020, to April 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an echocardiogram. 
 
You asked the Plan to pre-approve an echocardiogram. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an echocardiogram is covered for those indications 
listed in L33577. 
 
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 an echocardiogram. Our reviewer says 
that the requested echocardiogram is not medically reasonable and necessary. Our physician reviewer found 
that the enrollee is asymptomatic with mild aortic valve stenosis on an echocardiogram 2 years ago that is 
unchanged from 3 years earlier. In this circumstance, on a clinically stable patient without documented 
symptoms or change on physical exam, and with only mild stenosis, the records do not support the medical 
necessity for a repeat echocardiogram at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an echocardiogram have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an echocardiogram.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on April 8, 
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. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a knee orthosis (L1833) provided to the enrollee on April 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown. 
 
You asked the Plan to pre-approve the crown. You say that tooth #18 has a large filling with decay underneath. 
The Plan denied your request. The Plan says the crown 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 Plan's coverage rules apply in this case. The Plan covers the crown 
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 the crown. Our reviewer says that the 
criteria for coverage has not been met. Our physician reviewer found that there is an existing two surface 
restoration with no involved cusps or widespread damage to the tooth. Our reviewer says that a crown is not 
necessary for restoration on tooth #18. 
 
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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the crown.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
in the home health or hospice setting, each 15 minutes (CPT Code G0299 x60). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer 
found in order to require Home health care skilled services, the member must be confined to the home, under 
the care of a physician, and receiving services under a plan of care established and periodically reviewed by a 
physician. Additionally, the member must be in need of skilled nursing care on an intermittent basis or physical 
therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound 
means leaving home is a major effort. In this case, the documentation doesn't support that the member requires 
skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member 
does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order 
to improve the member's condition, perform a maintenance program to maintain the member's condition and/or 
prevent deterioration. The member has been medically stable without a recent decline in function. The member 
blood pressure is documented as being stable and they reside in an assisted living facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health or hospice 
setting, each 15 minutes (CPT Code G0299 x60).