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

We decided that the Plan does not have to waive the deductible for an outpatient surgery and copayment for a 
specialist office visit provided by a participating provider on July 15, 2020. 
 
You asked the Plan to waive the deductible and copayment for an outpatient surgery and a specialist office 
visit. You say that all the doctor did was snip off some brown spots on your back. You say that this was done in 
an office. The Plan denied your request. The Plan says the correct deductible and copayment have been applied 
 
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 $750 
deductible and a $35 copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $750 deductible for an outpatient surgery and a $35 copayment for a specialist 
office visit. The total amount you are being asked to pay is $176.74 ($141.74 + $35 = $176.74). 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 deductible and copayment for an outpatient surgery and a specialist office visit 
provided by a participating provider on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the aminolevulinic acid you received on 
July 13, 2020. 
 
You asked the Plan to waive the copayment for the aminolevulinic acid. You say that you have never had to 
pay this coinsurance in the past. The Plan denied your request. The Plan says you were charged this 
coinsurance 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% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the aminolevulinic acid. The aminolevulinic acid falls within 
the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
aminolevulinic acid you received on July 13, 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 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 do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. There is no 
documentation that you require the intensive rehabilitation therapy program provided in an IRF. Care at the 
skilled nursing facility level appears to be more appropriate in this case. 
 
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: 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. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for admission to acute inpatient rehabilitation. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, you have 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our 
reviewer also found that your care needs can be met at a lower level of 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided June 29, 
2020 to June 30, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you never left the 
Emergency Room and the inpatient copayment should not be applied. The Plan denied your request. The Plan 
says the services rendered were at the inpatient level of care and the correct copayment was applied. 
 
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 $260 
per day copayment for Inpatient Hospital Care.  
 
You have been asked to pay a $260 per day copayment for the inpatient hospital care. 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 inpatient hospital care provided June 29, 2020 to June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
not billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that submissions that are found to be incomplete or 
invalid are returned to the provider (RTP). An invalid submission is submission that contains complete and 
required information; however, the information is illogical or incorrect.  
 
We looked at the file and Medicare rules. Reporting diagnosis code C62.90 when the reported sex is female in 
this case, is incorrect/illogical. As such, the claim was correctly denied. It is also noted that the enrollee has a 
family history of testicular cancer, but this does not justify the use of code C62.90. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says treatment can be done at a lower level of care, such as outpatient treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found it is not 
expected that this enrollee would be able to improve in a reasonable period of time beyond the dates in 
question, as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and 
no abnormal or aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question 
as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health plan?s 
denial of continued inpatient psychiatric services appears appropriate. 
 
 
 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve (CPT Code E2313), (E2377) and (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
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 DME have not been met. The upgraded electronics (expandable 
controller, harness and electronic connector to 2 power options) are not medically necessary. They are 
necessary when there is a medical need to control power options though the joystick. The notes do not show a 
medical need to control the power options through the joystick. The power options can be controlled using their 
own switches. These switches can be made any size without asking for a separate request. They can be made 
from any material without asking for a separate request. All of this can be done without the need to use the 
joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve (CPT 
Code E2313), (E2377) and (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy services provided. 
 
You asked the Plan to pay for the chemotherapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 
chemotherapy services. 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 chemotherapy services provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram and tomomsynthesis rendered on May 28, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 77065 is 1. You billed 2 units of this code, exceeding the MUE. The MUE 
for CPT code G0279 is 1. You billed 2 units of this code, exceeded the MUE. 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 pay for the mammogram and tomomsynthesis rendered on May 28, 2019.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require an intensive, complex, multidisciplinary 
approach to daily therapy. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of 
a hip fracture after a fall. The enrollee's medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex device) 
(CPT Code 22869). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the device is not 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 the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer (Vertiflex device) (CPT Code 22869).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rytary. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Rytary.  
 
Benefits for this drug 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: Favorable

 
We decided that the Plan has to pre-approve Freestyle Libre sensors for the enrollee. 
 
You asked the Plan to pre-approve the sensors. You say that this is medically necessary. The Plan denied your 
request. The Plan says that it is not clear if there is adjustment of the insulin dosage based upon readings. 
 
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 sensors. Our reviewer says that the 
requested sensors are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is on daily insulin with type 2 diabetes, and has a four time a day flexpen with as needed 
coverage. The enrollee meets the criteria of checking blood sugar at least four times a day, and guiding 
coverage with readings. 
 
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 sensors have been met. Therefore, we decided that the Plan has to pre-
approve Freestyle Libre sensors for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided from November 
10, 2020, forward. 
 
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet criteria for acute inpatient mental health treatment as the patient was not shown to have passive danger to 
themselves but not others, auditory or visual hallucinations. The patient is noted to be cooperative and 
compliant with treatment while not showing any acute threat to safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care provided from November 10, 2020, forward.
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 based on the documentation provided, the health plan?s denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH for a neck abscess and bacteremia. 
The patient is not intubated/ventilated. There is no evidence that the patient requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the patient to the LTACH. The patient can remain at the current ACH until such time 
no acute services are required.  The patient can then be transferred/discharged to a lower level of care for any 
ongoing LTC needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that ventilators used to provide CPAP or bi-level CPAP 
therapy will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary for the enrollee in this case. The records do 
not indicate the enrollee has tried BiPap at home. The patient also does not have a neuromuscular disease. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.