Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) lumbar spine, with 
and without contrast (72158). 
 
You asked the Plan to pre-approve the MRI. You say that you do not agree with the plan's decision to deny and 
would like to appeal. The Plan denied your request. The Plan says there is insufficient information to approve 
the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when 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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found reviewed records do not include a detailed history of back pain, comprehensive physical 
examination of the musculoskeletal and neurologic systems, conservative therapies trialed, differential 
diagnosis, or care plan related to examination findings. Without the support of the documentation, 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) lumbar spine, with and without contrast (72158).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you under the flex benefit for eyeglasses provided on 
December 12, 2019. 
 
You asked the Plan to reimburse you for the flex benefit for eyeglasses. You say that you were unaware of the 
change to the flex benefit for 2019. The Plan denied your request. The Plan says the flex benefit was removed 
from your Plan effective January 1, 2019. 
 
The Plan must follow Medicare rules. Medicare rules say that a supplemental benefit is an item or service not 
covered by original Medicare, that is primarily health related and for which the MA plan must incur a non-zero 
direct medical cost. Supplemental benefits need not be provided through Medicare providers nor at Medicare 
certified facilities.  
 
We looked at the file and Medicare rules. The file shows that your Plan removed the flex benefit effective 
January 1, 2019. Therefore, we decided that the Plan does not have to reimburse you under the flex benefit for 
eyeglasses provided on December 12, 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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the policy requirements for inpatient rehab. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee'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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chair portion of a chair with seat lift mechanism. 
 
You asked the Plan to pre-approve chair. You say that this is a necessity for you and you would like for the 
chair and mechanism part to be covered. The Plan denied your request. The Plan says the denial of 
authorization for this item is correct, because the chair portion of a seat lift is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The chair portion of a seat lift 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 the chair portion of a chair with seat lift mechanism.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-evaluation of a limited oral exam (D0170) provided on 
January 13, 2020. 
 
You asked the Plan to pay for the dental service. You say that at the time of the date of service your plan 
covered this service. You say that 1 x-ray and exam are covered every year. The Plan denied your request. The 
Plan says the re-evaluation of a limited oral exam is not listed as a covered service. 
 
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 pay for the re-
evaluation of a limited oral exam (D0170) provided on January 13, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the injection, pegfilgrastim, provided on January 15, 2020. 
 
You asked the Plan to pay for the injection, pegfilgrastim (J2505). You say that this injection was medically 
necessary. The Plan denied your request. The Plan says that the injection did not meet NCD or LCD criteria. 
 
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 pay for the injection, pegfilgrastim (J2505). Our 
reviewer says that the injection was medically necessary. Our physician reviewer says the injection is approved 
as secondary prophylaxis per NCCN Compendia. 
 
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 injection, pegfilgrastim (J2505) have been met. Therefore, we decided that 
the Plan has to pay for the injection, pegfilgrastim, provided on January 15, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue by 
radiofrequency thermotherapy. 
 
You asked the Plan to pre-approve transurethral destruction of prostate tissue (53852). You say that the 
procedure is medically necessary. The Plan denied your request. The Plan says this procedure is not 
recommended for the enrollee's condition. 
 
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 transurethral destruction of prostate 
tissue (53852). Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found Transurethral Needle Ablation (TUNA) is not 
recommended by the American Urological Association as a treatment of lower urinary tract symptoms 
attributed to benign prostatic hyperplasia. Other surgical options are recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral destruction of prostate tissue (53852) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue by 
radiofrequency thermotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic or therapeutic injection with 
imaging guidance (62323) provided on May 8, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $0 or 
$275 copayment for each in-network Medicare-covered outpatient hospital facility visit. Enrollees pay a $0 
copayment for any surgical procedures (polyp removal) during a colorectal screening. Additionally, enrollees 
pay a $275 copayment for all other outpatient services including observation and outpatient surgical services 
not provided in an ambulatory surgical center. You can find this information on page 57 of the Plan?s 2020 
EOC.  
  
You have been asked to pay a $275 copayment for the surgical services provided at an outpatient hospital. 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 diagnostic or therapeutic injection with imaging 
guidance (62323) provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography and contrast materials 
(C9829 and A9700) provided on February 5, 2020. 
 
You asked the Plan to pay for the transthoracic echocardiography and contrast materials. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is 
the provider's responsibility to bill the Primary Group Health Plan or any liability insurance before submitting 
the claim to the member's Plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the transthoracic echocardiography and contrast materials until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for the transthoracic echocardiography 
and contrast materials (C9829 and A9700) provided on February 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the light cleaning, showering, dressing services, etc. received 
from October 4, 2019 to February 27, 2020. 
 
You asked the Plan to pay for these basic care services. You say that it was your understanding that the plan 
would cover these services 2 times a week for 2 hours per visit. The Plan denied your request. The Plan says 
the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for the light cleaning, showering, dressing 
services, etc. received from October 4, 2019 to February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace provided on March 19, 
2020. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that you were informed you wouldn't 
have a copayment. You say that you want this bill taken care of. 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% 
coinsurance for each Medicare-covered prosthetic device from an in-network provider. 
 
You have been asked to pay $274.24, which is 20% of the allowed amount for the back brace. The allowed 
amount is $1,371.22 (20% x $1,371.22 = $274.24). The back brace falls within the "Prosthetic devices and 
related supplies" 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 back brace 
provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services you 
received on April 29, 2020, and April 30, 2020. 
 
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says the claim processed 
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 20% 
coinsurance for outpatient hospital services.  
 
Review of the file shows that you were provided outpatient hospital services on April 29, 2020, and April 30, 
2020. You have been asked to pay a 20% coinsurance for the services, totaling $3,986.03. The services fall 
within the outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the outpatient hospital services you received on April 29, 2020, and April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory assist device (E0471) provided on September 
14, 2019. 
 
You asked the Plan to pay for the respiratory assist device. You say that you would like reconsideration 
because the diagnosis code was corrected. The Plan denied your request. The Plan says manifestation codes 
cannot be listed as the primary, first listed, or principal diagnosis on a claim because each describes a 
manifestation of some other underlying disease, not the etiology or disease itself. 
 
The Plan must follow Medicare rules. Medicare rules say that the underlying condition must be sequenced first, 
if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory assist device have not been met. Specifically, the claim was submitted with 
diagnosis code G47.37. Per the ICD-10, this code has a "code first" note indicating that any underlying 
condition should be sequenced first. Therefore, we decided that the Plan does not have to pay for a respiratory 
assist device (E0471) provided on September 14, 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. 
 
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 your needs can be safely accommodated at an alternate 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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your 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 does document a need for physical and occupational therapy, it does not document a need for an 
intensive rehabilitation program. 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. Our physician reviewer 
found that your 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on February 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 procedure code 95813 is 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. 
 
In this case, the CPT Code Manual definition of code 95813 is electroencephalogram (EEG) extended 
monitoring; 61-119 minutes. 
 
We find that CPT code 95813 is not supported in the medical record. Specifically, there is no documentation of 
an EEG with extended monitoring for 61-119 minutes. 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 electroencephalogram (EEG) rendered on February 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low back surgery (22633). 
 
You asked the Plan to pre-approve low back surgery. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve low back surgery. 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 documentation of adequate conservative measures to include a recent trial 
of physical therapy. Criteria for lumbar surgery has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of low back surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve low back surgery (22633).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on February 21, 2020. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the 
rendering provider is not participating with your plan for the date of service in question. There is no 
authorization on file for the services rendered. There are other providers within your network that are part of 
the Plan vendor and in-network provider listing. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine vision and 
eyewear benefit that exceeds Medicare coverage. Medicare rules say that plans can require enrollees to get care 
from network providers. The contract with the Plan says that the Plan has pay for care from out-of-network 
providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the 
Plan. The Plan did not pre-approve coverage for the eyeglasses. We found no exception that would require the 
Plan pay for the eyeglasses. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses 
provided on February 21, 2020.