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

 
We decided that the Plan does not have to pre-approve Ascent injections. 
 
You asked the Plan to pre-approve Ascent injections. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Ascent injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no studies to support the use of Ascent for the member?s condition. 
Additionally, there is no indication that Ascent offers any advantages over conventional treatment. Nor is there 
any information regarding clinical outcomes. The review has determined that the requested Ascent injections at 
issue in this case are not medically reasonable and 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 Ascent injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ascent injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the care required exceeds the clinical 
capabilities of all lower levels of care. The Plan denied your request. The Plan says the enrollee does not 
require services that cannot be given in the current location. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the current acute care hospital with wound infection 
bacteremia and leukocytosis. She was treated with wound care, debridement, incision and drainage for 
abscesses of the leg and IV antibiotics. The enrollee appears to be more stable at this time, but requires 
additional short term acute care services, which can be received in the current setting. The enrollee does not 
require services at the LTACH that are not already available at the current hospital. Therefore, this request for 
LTACH services will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services provided on June 24, 
2020. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you were not aware that the 
charges would be so high for a blood test. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received laboratory services on June 24, 2020. The record shows that you had only paid $31.59 toward the 
$300 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount 
of $228.70.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services 
were received on June 24, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
laboratory services provided on June 24, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for laboratory services provided on September 24, 2019. 
 
You asked the Plan to hold you harmless for the laboratory services. You say that you would like 
reconsideration because your doctor ordered these tests and they should be covered. The Plan denied your 
request. The Plan says that these services are not covered by Medicare. 
 
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 referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for laboratory services provided on September 24, 2019.  
 
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 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 you can safely continue receiving the services you need 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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform 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 medical services provided on July 2, 2020 to July 22, 
2020 by an out of network provider. 
 
You asked the Plan to pay for the medical services. You say that authorization should not be needed for the 
services rendered. The Plan denied your request. The Plan says you did not request prior authorization. 
 
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 service 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 on July 2, 2020 to July 22, 2020 by an out of 
network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT Codes: 22899 and C9752) 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of low back pain have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure remains experimental for treatment of LBP. More research is 
needed to show safety and efficacy. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT Codes: 22899 and C9752)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the arthrocentesis and methylprednisolone 
acetate injection provided on June 23, 2020. 
 
You asked the Plan to waive the cost share for the arthrocentesis and methylprednisolone acetate injection. You 
say that you already paid $40 for the injection but are getting billed a $21.07 copayment. The Plan denied your 
request. The Plan says the cost share applied 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 $20 
copayment for each primary care visit and 20% of the total cost for Medicare-covered Part B prescription 
drugs, including chemotherapy drugs.  
 
You have been asked to pay a total of $21.07 for the arthrocentesis and methylprednisolone acetate injection.  
 
Service Allowed Amount Standard Cost Member Liability 
Arthrocentesis $60.15 $20 $20 
Methylprednisolone 
Acetate Injection 
$5.35 20% $1.07 
TOTAL:   $21.07 
 
The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" benefit 
category. The methylprednisolone acetate injection falls within the "Medicare Part B prescription drugs" 
benefit category. Please contact the Plan for information on receiving a refund. 
 
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 cost share for the arthrocentesis and methylprednisolone acetate injection 
provided on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1851) 
 
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not show evidence of recent injury, surgery or joint laxity with 
knee instability. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that a knee immobilizer without joints (L1830), or a knee orthosis 
with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint 
that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the 
beneficiary has had recent injury to or a surgical procedure on the knee(s). 
 
  
 
 
The rules also say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a 
beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that 
Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the 
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer 
test). Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above 
criteria for coverage. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the items/services at issue in this case are not medically reasonable or necessary. In this 
case, there is no evidence of recent injury or surgery to the knee and there is no description of joint laxity. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1851)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee presented to the 
hospital on November 18, 2020 with shortness of breath. She underwent aortic valve replacement. 
The latest progress note indicates she has worsening acute hypoxic 
hypercapnic respiratory failure and needed to be put back on IV Lasix. She is not medically optimized to be 
transferred to an IRF. While she may benefit from further therapy, the records do not support that she could 
fully tolerate and participate in an intensive therapy program 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cardiology Next Generation Sequencing panel provided 
on January 30, 2020. 
 
You asked the Plan to pay for the Cardiology Next Generation Sequencing panel. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the Cardiology Next Generation Sequencing panel, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the Cardiology Next Generation Sequencing panel provided on January 30, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the open treatment of femoral fracture services coded 27236 
and the open treatment of ulnar fracture services coded 24685 provided on October 7, 2019. 
 
You asked the Plan to pay for the open treatment of femoral fracture services and the open treatment of ulnar 
fracture 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. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the open treatment of femoral 
fracture services coded 27236 and the open treatment of ulnar fracture services coded 24685 provided on 
October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital for an elective aortic valve replacement, tricuspid annuloplasty, patent foramen ovale 
closure, phrenic to phrenic pericardiectomy, pulmonary vein isolation, and left atrial appendectomy. She has 
required dobutamine for right heart failure which is slowly improving but she still has some edema. Vitals were 
stable without oxygen and she is ambulating according to recent notes. She appears to be stable at this time, 
requiring only short term acute care services which can be received in the current setting. She does not require 
services at the LTACH that are not already available at the current hospital. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current hospital. The LTACH 
services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee on August 10, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 home health services 
provided to the enrollee on August 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography, head or brain (70450) and 3D 
rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, 
or other tomographic modality (76376) provided July 16, 2020. 
 
You asked the Plan to pay for the diagnostic services. You say that the records attached supporting multiple 
procedures rendered on this date. Please reprocess charge for separate reimbursement. The Plan denied your 
request. The Plan says this claim has already been processed and paid. There is no additional documentation 
supporting additional studies were performed. 
 
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, we find that the submitted records support 1 (one) unit each of 70450-26 and 76376-26, which 
were previously approved and paid for by the Plan. There were no additional records provided that supports 
additional tests rendered. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for computed 
tomography, head or brain (70450) and 3D rendering with interpretation and reporting of computed 
tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376) provided July 
16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral device received on January 7, 2020. 
 
You asked the Plan to pay for the oral device. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the item received is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a prefabricated oral appliance is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oral device have not been met. Therefore, we decided that the Plan does not have to pay for the 
oral device received on January 7, 2020.