Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. 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 that, based on the medical records provided, 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 does require physical therapy and occupational therapy services 
but based on the medical records the enrollee does not require an intensive inpatient rehabilitation therapy 
program. There is no documentation that the enrollee requires the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveRhopressa.You asked the  Plan to pre-approveRhopressa.  You say that you  would  like  reconsideration  because  this  drug  is medically  necessary.The  Plan  denied  your  request.  The  Plan  says this  drug  is  not covered  under  Medicare  Part B.The  Plan  must  follow  Medicare  rules.  The  rules  say that  Medicare  Part B generally  doesnot 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-approveRhopressa.Benefits  for Rhopressamay be available  under Medicare Part D.Contactthe  Plan  that  administers  Part D benefits  for further  information  concerning  any  benefits  and appeal  rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98940) provided on May 11, 2020, to May 18, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe chiropractic manipulative treatment. You say that the OON provider was highly recommended.The Plan denied your request. The Plan says prior authorizationwas not obtained by the facility or the provider; therefore, payment has been correctly denied.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 forthe chiropractic manipulative treatment (98940) provided on May 11, 2020, to May 18, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 9, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you would like the plan to 
reconsider their decision. The Plan denied your request. The Plan says the services were processed correctly 
per your 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 a $210 
copayment for ambulance services.  
 
You have been asked to pay a $210 copayment for the ambulance services. The ambulance services fall within 
the ambulance 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 
ambulance services provided on July 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ultrasound provided by a non-
participating provider. 
 
You asked the Plan to waive the coinsurance for an ultrasound. You say that you do not know why the Plan did 
not cover this. The Plan denied your request. The Plan says the correct coinsurance 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). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for outpatient diagnostic tests/radiological diagnostic services/out-of-network.  
 
You have been asked to pay a 40% coinsurance of the allowed amount for an ultrasound. The total allowed 
amount is $322.17. The total amount you are being asked to pay is $128.87 ($322.17 x 40% = $128.87). An 
ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services/out-of-network 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 an ultrasound provided by a non-participating 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nitroglycerin, Pantoprazole, aspirin, Tramadol, 
Atorvastatin, Metoprolol Tartrate, and Donepezil Hydrochloride provided from June 25, 2020, to June 26, 
2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you are unable to pay this bill. The 
Plan denied your request. The Plan says self-administered drugs are not covered in an outpatient hospital 
setting. 
 
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 pay for the Nitroglycerin, Pantoprazole, 
aspirin, Tramadol, Atorvastatin, Metoprolol Tartrate, and Donepezil Hydrochloride provided from June 25, 
2020, to June 26, 2020.  
 
Benefits for the self-administered drugs 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on July 20, 2020. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you are entitled to a yearly eye 
exam with a $15 copayment. The Plan denied your request. The Plan says you must use an in-network provider 
and there is a $45 copayment for a Medicare-covered outpatient visit for an eye exam to diagnose and/or treat a 
disease or condition of the eye. 
 
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 $45 
copayment for a Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. 
 
You have been asked to pay $45 copayment for the eye exam. the eye exam falls within the vision 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 eye exam provided on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for eye surgery with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are 54 in-network providers available within a 20-mile radius of the enrollee's zip 
code. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for eye surgery with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approveacute  IRF admission  and  services.You asked the  Plan to pre-approveIRF care. The  Plan  denied  your  request.  The  Plan  says the enrollee  does not need specialized  therapeutic  skills  or equipment  that  require  an  inpatient  stay.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  requestto pre-approve  IRF care. Our physician  reviewer  found that  the  enrollee  is  weak and unsteady.  He is  walking  101-150 feet usinga cane with  minimal  assistance,and is at standby  to minimum  assist  for transfers  and activities  of  daily  living. The  complexityof the enrollee'snursing,  medical  and rehabilitation  needs  do not require  an  acute hospital  inpatient  stay  with  an interdisciplinary  approach  to rehabilitation  care. There  is  no documentation  that  the enrolleerequires  the intensive  rehabilitation  therapy  program  provided  in  an inpatient  rehabilitation  facility.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-approveacute  inpatient  rehabilitation  facility  (IRF)  admission  and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa shoulder injections (J7323). 
 
You asked the Plan to pre-approve Euflexxa shoulder injections. You say that this would improve the enrollee's 
function. The Plan denied your request. The Plan says more than one repeat injection is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat injections for shoulder arthritis are limited 
to a single repeat course. 
 
We looked at the file and Medicare rules. The record indicates that more than one repeat course is being 
requiested. Based on this information, we decided that Medicare rules for coverage of Euflexxa shoulder 
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa 
shoulder injections (J7323).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99350) provided on May 13, 2020. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because prior 
authorization rules do not apply. The Plan denied your request. The Plan says the appropriate code was not 
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 99350 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval 
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a 
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face 
with the patient and/or family.  
 
 
 
We find that CPT code 99350 is not supported in the record. Specifically, this claim was billed with Place of 
Service code 13 for Assisted Living Facility. It is not appropriate to bill home service codes for services 
provided in settings other than in a private residence. Based on this information, we decided that Medicare 
rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to 
pay for the home visit (99350) provided on May 13, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for IRF 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for BRCA1 and BRCA2 genetic testing provided on March 10, 2020. 
 
You asked the Plan to pay for genetic testing. You say that you are requesting coverage for this testing. The 
Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the 
enrollee did not meet the criteria for coverage of this testing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that their decision to deny payment for this 
testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for 
BRCA1 and BRCA2 genetic testing provided on March 10, 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: Practitioner Services
Decision: Unfavorable

We decided  that the  Plandoes not haveto pre-approvean Orthovisc  injection.You asked the  Planto pre-approvethe services.  You  say that without  these  shots,  the enrolleewon't  be able to walk.The  Plandenied  your  request. The  Plansayspart B step therapy  criteria  was not  met.Medicare  covers  Part B medications  when  they  are reasonable  and necessary  but allows  health  plans  to implement  step therapy  criteria.  The Plan's  contract  indicates  that  it  has  implemented  such  criteria  for  certain Part B medications.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 services.  Our reviewer  says that  the requested  injection  is  not medically  reasonable  or necessary.  Our physician  reviewer  found  the  enrollee  has not tried  or failed  Synvisc,  Durolane,  or Gelsyn-3. There is no documentation  provided indicating  that the plan's required  drugs  would  likely  be less  effective  and/or  likely  have  adverse  effects  for the  enrollee. 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  services  have  not been met.Therefore,  we decided  that the Plandoes not haveto pre-approvean Orthovisc  injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (G0481) provided on July 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 G0481 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records do not support 
that testing on more than 8 drug classes was performed on the date of service in question. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (G0481) provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99397, 99213) provided on January 14, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe office visit. You say that you were unaware the provider was out of network with this particular plan.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider;therefore, payment has been correctly denied.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 forthe office visit (99397, 99213) provided on January 14, 2020, by an out-of-network (OON) provider.
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 enrollee needs additional time to regain strength. 
The Plan denied your request. The Plan says the enrollee's current level of function does not require intensive, 
complex interdisciplinary therapy in the acute inpatient setting. 
 
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 described as lethargic throughout, with slowed processing, following 75% of commands. 
While the enrollee has complex nursing, medical and rehabilitation needs, the documentation does not support 
that the enrollee is appropriate for an acute rehabilitation hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The documentation does not support that the enrollee can participate in a 
rehabilitation therapy program sufficient for this level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.