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

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided by a 
specialist on March 11, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy provided by a specialist. You say 
that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider 
your request. The Plan denied your request. The Plan says you received a diagnostic colonoscopy provided in a 
specialist's office on the date 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 $30 
copayment for each specialist visit.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a diagnostic 
colonoscopy provided in a specialist's office on March 11, 2020. You have been asked to pay a $30 copayment 
for the diagnostic colonoscopy provided by a specialist. The diagnostic colonoscopy provided in a specialist's 
office falls within the Physician/Practitioner 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 
copayment for the diagnostic colonoscopy provided by a specialist on March 11, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer 
compression system to the leg during an occupational therapy visit provided on January 6, 2020 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application. You say 
that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a 
$25 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $30 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $25 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi-layer compression system to the leg during an occupational therapy visit provided on January 6, 
2020 billed with code 29581-GO.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport to a physician's 
office on January 24, 2020. 
 
You asked the Plan to pay for the non-emergency ambulance transport to a physician's office. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport to a 
physician's office on January 24, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room Services (99284) 
provided May 22, 2020. 
 
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment 
should be waived. The Plan denied your request. The Plan says the correct copayment was assessed. 
 
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 $100 
copayment for Emergency Care.  
 
You have been asked to pay a $100 copayment for the Emergency Room Services. The Emergency Room 
Services fall within the Emergency Care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for Emergency Room Services (99284) provided May 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of The 
Aorta, Magnetic Resonance Angiography of The Pelvis, Magnetic Resonance Angiography of The Abdomen, 
and Magnetic Resonance Angiography of The Lower Extremity. 
 
You asked the Plan to pre-approve these MRAs. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MRAs are covered for certain indications. 
 
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 MRAs. Our reviewer says that the 
documentation does not support that the requested MRAs are medically reasonable or necessary. Our physician 
reviewer found the enrollee has no objective evidence of arterial embolization and has normal distal pulses and 
toe pressures. The enrollee has foot pain and is status post multiple foot surgeries offering a more likely 
etiology than arterial embolization. The vascular provider acknowledges that an MRA in this setting is likely to 
be low yield. The chances of the MRA demonstrating actionable disease is very low. Therefore, the enrollee 
does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these MRAs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Magnetic Resonance Angiography (MRA) of The Aorta, Magnetic Resonance 
Angiography of The Pelvis, Magnetic Resonance Angiography of The Abdomen, and Magnetic Resonance 
Angiography of The Lower Extremity.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee required moderate assistance for sit to stand. The enrollee required 
maximum assistance with bed mobility. The documentation does not support that the enrollee requires an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may benefit 
from further physical therapy and occupational therapy, the enrollee does not require 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRA, abdomen, with or without contrast material(s) 
(CPT Code 74185). 
 
You asked the Plan to pre-approve the MRA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 MRA. Our physician reviewer 
found MRAs are appropriate and useful in the setting of patient's having evidence of large vessel disease 
affecting blood flow such as in the setting of an abnormal ABI or Doppler study and would not be indicated 
unless strong consideration for an invasive procedure is being planned. In the setting of this patient with left 
foot pain and mild discoloration, the MRA would not be appropriate. The ABI was normal, Doppler was 
normal, and there was no other signs or symptoms suggestive of a significant large vessel occlusion/obstruction 
to warrant MRA. Therefore, this request for such will be considered not medically necessary based on the 
provided documentation. 

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 MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRA, abdomen, with or without contrast material(s) (CPT Code 74185).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right lumbar L5-S3 radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve right lumbar L5-S3 RFA. 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 right lumbar L5-S3 RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a meta-analysis of randomized trials showed that radiofrequency ablation for patients 
with low back pain resulted in no or modest improvement of pain in the short-term compared to placebo, but 
did not result in long-term improvement of pain or function. The medical literature does not support that RFA 
is medically reasonable and necessary in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of right lumbar L5-S3 RFA have not been met. Therefore, we decided that the 
Plan does not have to pre-approve right lumbar L5-S3 radiofrequency ablation (RFA).
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 the enrollee does not 
need 24-hour nursing, frequent physician visits, or special equipment. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for left knee pain. Her medical conditions are stable. The 
complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation 
that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. While the medical record supports need for physical and occupational therapy services, it 
does not support a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment charged for specialist services provided on 
May 26, 2020. 
 
You asked the Plan to waive this service. You say that you do not believe this copayment is correct. The Plan 
denied your request. The Plan says this copayment was charged based on your Plan contract agreement. 
 
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 $40 for 
each specialist visit. 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 $40 copayment charged for specialist services provided on May 26, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hematology/oncology services to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you may have cancer and it needs to be 
attached right away. The Plan denied your request. The Plan says there are multiple in-network providers 
available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
hematology/oncology services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that IRF services were medically necessary. The Plan denied 
your request. The Plan says coverage criteria was not met. 
 
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 pay for 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 records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication 
management, wound care, and daily therapy can be provided 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT Code 64493) x 2, (CPT Code 64494) x 2, and (CPT Code 64495) x 2. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested procedure is supported at a frequency of two (2) injections to 
diagnose facet pain, or a maximum of five (5) facet joint procedures per twelve (12) months. The Plan states 
the records they received shows that you have exceeded this limit. 
 
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 services have not been met. You have exceeded this limit for 
this service. The rules say that a maximum of five (5) facet joint injection sessions inclusive of medial branch 
blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per rolling 12 month 
year in the cervical/thoracic spine and five (5) in the lumbar spine. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
Code 64493) x 2, (CPT Code 64494) x 2, and (CPT Code 64495) x 2.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Tobramycin (J7682). 
 
You asked the Plan to pre-approve a tier exception for Tobramycin. You say that the tier exception is 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping 
Part D drugs into different cost sharing levels within a Part D sponsor's formulary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a tier exception for Tobramycin have not been met. Specifically, the requested drug is covered 
under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part B Drugs are not 
subject to tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for 
Tobramycin (J7682).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRA, lower extremity, with or without contrast 
material(s) (CPT Code 73725). 
 
You asked the Plan to pre-approve the MRA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 MRA. Our physician reviewer 
found this patient has a report of left foot pain and mild discoloration. MRA lower extremities was requested. 
The patient did not report any signs or symptoms classic for claudication and physical findings including ABI 
and Doppler study of the lower extremities did not show evidence of large vessel disease. MRA is only 
justified in the setting of other evidence suggestive of large vessel occlusion/obstruction causing symptoms and 
warranting intervention. As the provided notes do not support this test in this clinical setting, the MRA will be 
considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRA, lower extremity, with or without contrast material(s) (CPT Code 73725).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRA, pelvis, with or without contrast material(s) 
(CPT Code 72198). 
 
You asked the Plan to pre-approve the MRA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 MRA. Our physician reviewer 
found this patient had been experiencing left foot pain with mild discoloration. A request for MRA pelvis was 
made. The patient had a Doppler study and ABI measurements which were essentially normal showing no 
evidence of large vessel occlusion/obstruction. MRA is only indicated for when initial assessment from 
physical examination, reported symptoms suggestive of claudication, and/or Doppler or ABI being abnormal, 
none of which were evidence in this case based on the provided documentation. Therefore, this request for 
MRA pelvis will be considered not medically necessary 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 the MRA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRA, pelvis, with or without contrast material(s) (CPT Code 72198).