Persius/hicric huggingface dataset:
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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke and was transferred to a rehabilitation facility on March 5, 2021, then discharged home with home health physical therapy on March 31, 2021. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulsed radiofrequency ablation (RFA) (C64635, 64636).
You asked the Plan to pre-approve the pulsed RFA. You say that you have been falling due to your chronic
back issues. The Plan denied your request. The Plan says Medicare does not cover pulsed RFA.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pulsed RFA have not been met. Therefore, we decided that the Plan does not have to preapprove
pulsed radiofrequency ablation (RFA) (C64635, 64636).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet block injections.
You asked the Plan to pre-approve these services. You say that you can't do anything due to the pain. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that facet injections are covered when specific criteria
are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have chronic low back pain. There is documented lumbar spinal stenosis (narrowing of the spinal canal), facet
joint disease, and degenerative abnormal alignment of the spine. There are other documented possible pain
sources and other therapies available for treatment. The facet blocks are therefore 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet block injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit and laboratory services, provided
by an out-of-network provider on November 23, 2020.
You asked the Plan to pay for the annual wellness visit and laboratory services. You say that you needed a
wellness check to get your medications renewed. You say that you were informed insurance covered wellness
checks, and the bill should be covered. The Plan denied your request. The Plan says members must use network
providers to get medical care and services.
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 had network providers
available who could have provided 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 annual wellness visit and laboratory services,
provided by an out-of-network provider on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic blood pressure monitor (A4670) and a blood pressure apparatus (A4660) provided on October 1, 2020.

You asked the Plan to pay for an automatic blood pressure monitor and a blood pressure apparatus. You say that the requested items are necessary to care for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The items at issue in this appeal do not serve a purpose that is primarily medical in nature because they are primarily preventative. These items are 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 pay for an automatic blood pressure monitor (A4670) and a blood pressure apparatus (A4660) provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiotherapy 3DCRT boost treatments (77014, 77263,
77280, 77290, 77295, 77300, 77301, 77307, 77321, 77331, 77334, 77336, 77338, 77370, 77412, 77417, 77427,
77470, G6013).
You asked the Plan to pre-approve radiotherapy 3DCRT boost treatments. You say that the medical records
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says based on
the records received the service requested is not medically necessary for the enrollee's diagnosis.
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 radiotherapy 3DCRT boost treatments.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found there is no history and physical provided and no assessment and plan
by the radiation oncologist. There are no clinical records or notes from the radiation oncologist justifying the
need for the boost. There are no records showing that the enrollee had positive surgical margins. The records
do not indicate why 10 fractions were requested as opposed to the more standard 4-5 (for those with justifiable
need) or 7-8 (for this with high risk factors) fractions.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiotherapy 3DCRT boost treatments have not been met. Therefore, we
decided that the Plan does not have to pre-approve radiotherapy 3DCRT boost treatments (77014, 77263,
77280, 77290, 77295, 77300, 77301, 77307, 77321, 77331, 77334, 77336, 77338, 77370, 77412, 77417, 77427,
77470, G6013).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kyphoplasty procedure.
You asked the Plan to pre-approve the requested services. You say that you are in severe pain. The Plan denied your request. The Plan says your fracture occurred over 6 months ago.
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is only covered under certain medical conditions. We looked at the file and Medicare rules. The records provided do not show that your condition is acute. 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 pre-approve a kyphoplasty procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out-of-network vascular surgeon.
You asked the Plan to pre-approve an out-of-network office visit. You say that this doctor is the only one that can help you. The Plan denied your request. The Plan says in-network community level of care providers are available.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 out-of-network office visit. Our reviewer says that the documentation does not support the need for tertiary level services. Our reviewer says that you have been prescribed compression stockings and a lower extremity venous duplex has been ordered, which is a reasonable approach. Our physician reviewer found that the medical records do not demonstrate a unique aspect of your condition that would necessitate out-of-network care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an out-of-network office visit have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit with an out-of-network vascular surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four precision attachments (D5862 x4).
You asked the Plan to pre-approve the precision attachments. You say that you need these services to be approved. 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. Therefore, we decided that the Plan does not have to pre-approve four precision attachments (D5862 x4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from July 24, 2020, through
July 25, 2020.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says these
services required prior authorization.
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for an inpatient admission provided from July 24, 2020, through July
25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from September 18,
2020, to September 22, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these drugs were coded incorrectly.
The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from September 18, 2020, to September 22, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 12, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on August 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection provided on September 21,
2020.
You asked the Plan to waive the coinsurance for the injection. You say that you do not have copayments for
these services, and you should not be responsible for the bill. The Plan denied your request. The Plan says the
coinsurance 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 20% of
the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs.
You have been asked to pay $126.98, which is 20% of the allowed amount for the injection. The allowed
amount is $634.90 (20% x $634.90 = $126.98). The injections fall 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 coinsurance for the injection provided on
September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on January 23, 2021.
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this code is bundled to another service billed on the same day by the same physician, or a physician of the same specialty in the same group, which is considered the same provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 71045 is "Radiologic examination, chest; single view." We asked our coding 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 reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation does not support a separate or increased procedural service, therefore it is inappropriate to bill these two CPT codes on the same day. Two claims were submitted by the provider. The first 820210280346278 for date of service January 23, 2021 for CPT 71100 Radiological examination, ribs, unilateral; 2 views with multiple other procedures, and second claim 820210280346120 for date of service January 23, 2021 for CPT 71045 Radiologic examination, chest; single view. We looked at this coder'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 pay for radiology services (CPT 71045) provided to the enrollee on January 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 18, 2020.
You asked the Plan to pay for the ConfirmMDx testing. The Plan denied your request. The Plan says the testing is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is covered for the indications established in the applicable LCD.
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 ConfirmMDx testing. Our reviewer says that the requested ConfirmMDx testing is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is noted to have previously treated prostate cancer. He currently has a rising PSA level and radiographic suspicion of metastatic disease. The performed genetic testing was not necessary to diagnose, treat or otherwise manage the enrollee's 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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 18, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the therapy the enrollee needs cannot be provided at a lesser intense level of care. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve these 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee pain. She received Zilretta in both knees in January of 2021 with good relief. Repeat Zilretta injections are not FDA-approved and the services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycapssa DR, 20 mg capsule.
You asked the Plan to pre-approve Mycapssa. You say that the enrollee has many end-organ effects from
acromegaly. You say that the enrollee has not been able to tolerate standard therapy for acromegaly. You say
that these symptoms are getting worse to the point of requiring more joint replacements. You also say that
untreated acromegaly increases the risk of cardiomyopathy in the future as well as increased risk of cancer. The
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says selfadministered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mycapssa DR, 20 mg
capsule.
Benefits for Mycapssa may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub.
You asked the Plan to pre-approve a walk-in bathtub. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this is not a covered item.
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.