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

 
We decided that the Plan does not have to pre-approve Keytruda 100MG/4ML Solution (CPT Code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found no, this drug is not FDA-approved without documentation of testing of PD-L1, ALK, or EGFR, and no, 
this use is not supported in any of the major drug compendia or CMS-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda 100MG/4ML Solution (CPT Code J9271).
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 this request exceeds your needs. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99212), injection (J1110), 
arthrocentesis, aspiration and/or injection small joint without ultrasound guidance (20600), radiologic 
examination of foot (73630) and new outpatient office visit (99202) provided on May 1, 2020 to May 8, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you were advised the provider was in 
network. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide 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 office outpatient visit (99212), injection 
(J1110), arthrocentesis, aspiration and/or injection small joint without ultrasound guidance (20600), radiologic 
examination of foot (73630) and new outpatient office visit (99202) provided on May 1, 2020 to May 8, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for epidurography (72275) provided on January 22, 2020.
You asked the Plan to pay for the epidurography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
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 72275 is epidurography, radiological supervision and interpretation. We asked our coder 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 epidurography. Our reviewer says that CPT code 72275 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted does not include a record of the images. 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 epidurography have not been met. Therefore, we decided that the Plan does not have to pay for epidurography (72275) provided on January 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
December 7, 2019. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you were told that you 
would be admitted to the hospital, and believe that the hospital claimed you were in observation to avoid re-
admission status and ensure they would be paid. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $90 
copayment for emergency room visit. The record shows that after this emergency room visit you were admitted 
to the hospital for outpatient observation, but you were not admitted for inpatient hospital care. Therefore, the 
emergency care copayment is not waived for this claim. 
 
 
 
 
You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls 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 an emergency room 
visit provided on December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that the claim should be paid.The Plan denied your request. The Plan says compression stockings are not a covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the left knee x-ray provided on April 24, 2020. 
 
You asked the Plan to pay for the x-ray interpretation. You say that the record is provided to support the claim 
as billed. The Plan denied your request. The Plan says that according to the ICD-10-CM Official Guidelines for 
Coding and Reporting, some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a 
more specific (e.g. bilateral) code is available; therefore, the reported service has been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that some diagnosis codes indicate laterality. If the 
side is not identified in the medical records, the unspecified side is assigned. 
 
In this case, although the x-ray was done on the left knee, there is no indication in the available record 
specifying which side the knee laceration is on. The ICD-10 coding guidelines indicate unspecified side is 
appropriate in this case. Therefore, we decided that the Plan has to pay for the interpretation of the left knee x-
ray provided on April 24, 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: 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 review of available records, you do not meet Medicare criteria for coverage 
for an IRF admission. You are medically not quite stable. You have dementia, not following commands and 
confused, with restraints in place. While you may benefit from continuing physical therapy (PT) and 
occupational therapy (OT), there is no evidence of need for an intensive therapy program with or therapy three 
(3) hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. 
Admission to IRF is not medically necessary based on lack of medical stability and dementia. Your rehab 
needs can be met at an alternate, low intensity level setting such as a skilled nursing facility (SNF) once stable. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination (X-Ray) of chest (71045), 
transport of X-Ray equipment (R0070) and set up of portable X-Ray (Q0092) provided on February 21, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for transport and set-up of portable X-Ray equipment and X-Ray of chest. You say 
that the services rendered have never been denied. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide 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 radiologic examination (X-Ray) of chest 
(71045), transport of X-Ray equipment (R0070) and set up of portable X-Ray (Q0092) provided on February 
21, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay was 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. The enrollee is medically stable and can receive further rehab services at a lower level 
of care.  Although further rehab services would be appropriate to improve function, as a practical matter, the 
daily skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does 
not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is 
medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function 
is at or near their baseline and the enrollee can receive services at a lower level of care. Admission to a SNF for 
inpatient skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 you will fall again if you do not get this service. The Plan denied your request. The Plan says you do not have rehab needs that can only be met in an IRF. 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 you were admitted to the acute hospital for a right femoral neck fracture status post right hip hemiarthroplasty. Your right hip is stable, and there was no chest pain, shortness of breath, or leg edema. You are at a supervision level for grooming and ambulation. 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 status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from physical and occupational therapy, but the documentation does not support that you high functional status requires an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 met at a lower 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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be 
able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care 
needs can be met at a lower level of care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on February 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this 
service is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on February 
21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on March 12, 2020 to March 27, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this should only be for 4 
days, not 5. The Plan denied your request. The Plan says the correct copayment has 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $320 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient 
hospital care.  
 
The enrollee has been asked to pay a $320 copayment per day for days 1-5. There is a $0 copayment for 
additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,600 ($320 x 5 
days = $1,600). The correct copayment has been applied to the services provided. An inpatient hospital stay 
falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay provided by a participating provider on March 12, 2020 to March 27, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on July 1, 2020.
You asked the Plan to pay for periodontal maintenance (D4910). You say that you were never informed the
provider was out-of-network. You say that the charge should be overturned because you were not given the
appropriate information. The Plan denied your request. The Plan says the claim processed correctly.
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, you also have a $40 copayment for
periodontal maintenance. Therefore, we decided that the Plan does not have to pay for periodontal maintenance
(D4910) provided on July 1, 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 member's safety is at risk as member is unable to 
ambulate alone and unable to go home due to safety issues. 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 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 
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.