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

We decided that the Plan does not have to pre-approvefor computed tomography (CT) of abdomen and pelvis (74177).You asked the Plan to pre-approvethe CT scan. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the records do not support that the CT scan is medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 therequest to pre-approve the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a September 2020 office note vaguely indicates that the enrollee had left upper quadrant abdominal pain.  No documentation as to the onset, nature or quality of the pain is noted.  At an October 2020 follow-up it is was noted that the enrollee had not been experiencing ongoing pain, but that she had had pain the day before the follow-up visit.  Interim labs were normal.  The documentation is insufficient to support that the requested CT scan is currently medically necessary or reasonable.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvefor computed tomography (CT) of abdomen and pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received from an out-of-network provider from October 2, 2019, to November 22, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-network.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe services you received from an out-of-network provider from October 2, 2019, to November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork provider on July 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical items provided on May 7, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the OON medical items. You say that the documentation supports the medical
necessity and order. The Plan denied your request. The Plan says authorization was not obtained.
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 items 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 medical items provided on May 7, 2020 by an out of network
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit on June 30, 2020.
You asked the Plan to waive the copayment for the nurse practitioner service. You say that the visit was in your
PCP's office. The Plan denied your request. The Plan says you were charged the copayment 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 $35
copayment for specialist visit.
You have been asked to pay a $35 copayment for the nurse practitioner service. The nurse practitioner service
falls within the specialist visit 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 office
visit on June 30, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora total shoulder arthroplasty and inpatient stay provided to the enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that there is no basis for this denial of inpatient services.The Plan denied your request. The Plan says that there was no approved authorization on file for this service.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was discharged when the provider felt that he was stable. It is reasonable for this length of inpatient stay after a total shoulder arthroplasty.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay fora total shoulder arthroplasty and inpatient stay provided to the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for complete ultrasound real time with image
documentation, abdomen (76700) and ultrasound, pelvic (non-obstetric), real time with image documentation
(76857) provided July 17, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you do not understand
why you have to pay every time you go to these tests. You are not working and cannot afford. Please
reconsider on this very bad and sad time to pay them. The Plan denied your request. The Plan says this claim
was processed with the correct copayment applied per the plan benefits.
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 $110
copay for each Medicare covered radiological diagnostic service, not including x-rays performed in a
physician's office or at a free-standing facility, such as a radiology center or medical clinic.
You have been asked to pay $167.13 for the diagnostic services. For 76857 the plan allowed $57.13 which is
lower than the $110 copayment. The diagnostic services fall within the Outpatient diagnostic tests and
therapeutic services and 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 copayment for complete ultrasound real time
with image documentation, abdomen (76700) and ultrasound, pelvic (non-obstetric), real time with image
documentation (76857) provided July 17, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor for use with interstitial continuous glucose 
monitoring coded with A9276. 
 
You asked the Plan to pre-approve the sensor. You say that this is medically necessary for you. The Plan 
denied your request. The Plan says that your request is not a covered benefit because you are requesting 
supplies for a non-therapeutic device which is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the 
DME benefit are defined as therapeutic CGMs and code A9276 is used to describe the supplies used with a 
non-therapeutic CGM. 
 
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting 
supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and 
supplies. Therefore, we decided that the Plan does not have to pre-approve a sensor for use with interstitial 
continuous glucose monitoring coded with A9276.
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 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 
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 sepsis and a urinary 
tract infection. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
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 services can be safely received in other settings, for example: a skilled nursing 
facility or home with home health services. 
 
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 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 (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for testing provided to the enrollee on June 22, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare Local Coverage Articles for billing and coding of MolDX: Targeted and 
Comprehensive Genomic Profile Sequencing Testing in Cancers (A55624) and MolDX: NEXT-
GENERATION Sequencing for Solid Tumors (A57858) require use of CPT 81479, and the appropriate DEX Z 
identifier entered adjacent in the comment narrative field. The Plan states the claim submitted does not include 
the required codes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted is lacking the codes 
required for this testing. Medicare rules for coverage of this testing have not been met. Therefore, we decided 
that the Plan does not have to pay for testing provided to the enrollee on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Depo-Testosterone. 
 
You asked the Plan to pre-approve the Depo-Testosterone. You say that the drug in dispute is medically 
necessary. You say that the enrollee has been taking this drug for several years and it has always been covered. 
The Plan denied your request. The Plan says the enrollee only has Part A and Part B coverage, and not Part D 
drug coverage through this Plan. 
 
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 Depo-Testosterone.  
 
Benefits for the Depo-Testosterone 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) 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 needs can be met 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. Our 
physician reviewer found 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 (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased July 15, 2020, from an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were never advised you would be OON. The 
Plan denied your request. The Plan says there is no coverage for hearing aids or related services if received 
from an OON provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plan's hearing aid vendor. 
 
We looked at the file and the Plan's rules. The case record indicates that the hearing aids were purchased from 
an OON provider and not from the Plan's hearing aid vendor. Based on this information, we decided that the 
Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not 
have to pay for the hearing aids purchased July 15, 2020, from an out-of-network (OON) provider.
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 IRF care is necessary to treat your medical condition. 
The Plan denied your request. The Plan says rules for IRF care have not been 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 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 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. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare guidance for use of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to 
have anemia, related to cancer and cancer treatment, for which she takes Retacrit. It is unclear how long the 
enrollee has been taking Retacrit. It is unclear what the enrollee's baseline labs were prior to starting Retacrit. 
While the enrollee's current Hgb is less than 10g/dL, it is unclear what, if any, response the enrollee has had to 
the drug. As such, the documentation does not support that ongoing use of Retacrit is currently medically 
necessary or reasonable. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on February 6, 2020. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test  results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
genetic testing rendered on February 6, 2020.