Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for respiratory flow volume loop provided. 
 
You asked the Plan to pay for respiratory flow volume loop (94375). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says that the documentation submitted does not support the 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file, and Medicare rules. Spirometry documentation for the claim date is included in the file. 
The Plan has not clearly explained as to why the medical records provided do not reflect a respiratory flow 
volume loop test. Therefore, we decided that the Plan has to pay for respiratory flow volume loop.  
 
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 Plan does not have to waive the coinsurance for the rituximab injection (J9312) and the 
chemotherapy administration (96413, 96415) provided on March 20, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40% 
coinsurance for each out of network Medicare-covered chemotherapy drug and the administration of that drug. 
Additionally, enrollees must pay a 40% coinsurance for each out of network Medicare-covered Part B drug.  
 
You have been asked to pay $1,482.54 ($7,412.69 Plan allowed amount x 20% coinsurance) for the Medicare-
covered chemotherapy administration and the Medicare-covered Part B drug injection provided. The claim has 
been processed at the in-network benefit level, which is less than the applicable out of network coinsurance. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the rituximab injection (J9312) and the chemotherapy 
administration (96413, 96415) provided on March 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 22, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 18, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service requires 
the use of code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on April 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurolysis facet nerve injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the maximum amount of this service has already been received. 
 
The Plan must follow Medicare rules. Medicare rules say that five facet injection sessions are covered per year.  
 
The records show five sessions have already been undergone prior to this request. Based on this information, 
we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a neurolysis facet nerve injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar spinal fusion (22633, 22634, 22842, 22853). 
 
You asked the Plan to pre-approve lumbar spinal fusion. 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 follows Medicare rules. Medicare rules say that lumbar spinal fusion is not considered medically 
necessary and is noncovered for certain conditions. 
 
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 lumbar spinal fusion. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found coverage criteria for spinal fusion 
is not met. There is no documented spinal instability, fracture, or lesion. Fusion is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spinal fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar spinal fusion (22633, 22634, 22842, 22853).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services provided on May 22, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 debridement services provided on May 22, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec 75mg ODT tablets. 
 
You asked the Plan to pre-approve the Nurtec tablets. You say that this medication is necessary. The Plan 
denied your request. The Plan says this oral drug is not covered by Medicare Part B. 
 
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 Nurtec 75mg ODT tablets.  
 
Benefits for the Nurtec tablets 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the records show the enrollee does not need to be seen by a rehab 
doctor three times per week, nor does she need an intensive team for care. The Plan says that the enrollee can 
safely receive the services needed in another 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for shortness of breath. She had surgery on her tricuspid valve and a MAZE procedure for atrial 
fibrillation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. 
The enrollee 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 enrollee 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the level of care provided was 
medically reasonable and necessary. The Plan denied your request. The Plan says the enrollee was stabilized 
prior to admission and that the hospital failed to request authorization. 
 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was stabilized 
in the emergency department and should have been considered for transfer to an approve 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 the inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are zero trips remaining. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 close physician involvement, and 
is able to do 3 hours of therapy a day. The Plan denied your request. The Plan says the enrollee's medical care 
is not complex. 
 
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 is at a minimal assist level for grooming, and minimal to moderate assist for dressing. 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. 
 
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 copayment for the specialist visit. 
 
You asked the Plan to waive the copayment for the specialist visit. 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 services provided by an out-of-network specialist on the date of 
service at issue in this appeal. The Plan says 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 $50 
copayment for each Medicare-covered specialist office visit provided by an out-of-network provider.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received office visit 
services provided by an out-of-network specialist on May 11, 2020. You have been asked to pay a $50 
copayment for the specialist visit. The specialist visit 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 specialist visit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc injections (J7327). 
 
You asked the Plan to pre-approve Monovisc injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when 
specific criteria is met. 
 
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 Monovisc injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the clinical information submitted 
indicates that you have had less than 3 months of conservative treatment and no imaging results were provided. 
The coverage criteria have not been met. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Monovisc injections (J7327).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided January 10, 
2020 to January 17, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the copayment should be 
waived. The Plan denied your request. The Plan says the correct copayment was 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 $295 
copayment for inpatient care.  
 
You have been asked to pay a $295 copayment for inpatient hospital care. 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 inpatient hospital care provided January 10, 2020 to January 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the upper extremity. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records did not show a trial of physical therapy or a shoulder x-ray. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no plain x-
rays. There has no been conservative management, such as PT, prescribed. You did have short term relief of 
symptoms with subacromial steroid injection. Absent any red flags and absent any plain x-rays you do not meet 
the qualifications for medical necessity of MRI of the left shoulder prior to a 6 week trial of PT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the upper extremity.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the fluid circulating cold pad with pump provided on January 29, 2019. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the item received is not a covered 
benefit. 
 
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 follows these rules. 
 
You were provided the fluid circulating cold pad with pump by a contract provider. The file does not show that 
the Plan provided notice that the fluid circulating cold pad with pump would not be covered. Under Medicare 
rules, this means the fluid circulating cold pad with pump is considered approved by the Plan. Therefore, we 
decided that the Plan has to hold you harmless for the fluid circulating cold pad with pump provided on January 
29, 2019 minus any cost share requirement.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy visits. 
 
You asked the Plan to pre-approve additional visits. The Plan denied your request. The Plan says the enrollee 
does not have the potential to improve, due to frequent non-participation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our physician 
reviewer found that the requested additionally therapy is not generally accepted as specific and effective 
therapy for your condition. You have had prior therapy and could not tolerate it. Your orientation and problem 
solving are impaired and would make carryover with therapy difficult. Your activities of daily living are 
addressed by staff at baseline. Your current needs do not require the unique skills of a professional therapist to 
safely and effectively provide treatment only by a therapist, or under the supervision of a therapist. The   
specialized skill of a qualified therapist is not required to deliver a program to maintain your current condition, 
or to prevent/slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional occupational therapy visits.