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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires long term acute 
care. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current 
acute setting. 
 
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 considered medically reasonable and necessary in this case. Long term 
acute care hospitals are certified as acute care hospitals, and in general, LTACHs do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include CPAP support with oxygen supplementation, tracheostomy care, intravenous antibiotics, 
surveillance laboratory studies, sacral wound care, tube feeding and therapy services. The documentation does 
not support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for drug testing provided on October 21, 2019. 
 
You asked the Plan to pay for drug test. You say that you are appealing with records to support the code billed. 
The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the 
documentation received does not include definitive laboratory results for 22 or more drug classes to support the 
code 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 G0483 is drug test(s), definitive; qualitative or quantitative, all sources, includes specimen validity 
testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the documentation submitted 
includes results for 22 or more drug classes. Based on this information, we decided that Medicare rules for 
coverage of drug test have been met. Therefore, we decided that the Plan has to pay for drug testing provided 
on October 21, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a OnabotulinumtoxinA (Botox) injection, 400 units. 
 
You asked the Plan to pre-approve Botox. You say that the requested injection is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the 
requested injection is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has failed surgical treatment of BPH or does not have overflow incontinence. The 
reviewer found that previous treatment with silodosin and tamsulosin has not been effective. Therefore, the 
reviewer found that the requested injection of OnabotulinumtoxinA injection, 400 units, is not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a OnabotulinumtoxinA (Botox) injection, 400 units.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) and simple repair of 
superficial wounds (12002) provided on June 18, 2020. 
 
You asked the Plan to pay for the emergency department visit and simple repair of superficial wounds. You say 
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan 
says the services rendered would need to be billed to Original Medicare based on the enrollee's hospice 
coverage. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit (99284) and simple repair of 
superficial wounds (12002) provided on June 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OPDIVO and Leuprolide Acetate for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this drug in this case requires use as a single agent for recurrent or metastatic 
disease as second-line systemic therapy post-platinum. 
 
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 drugs. Our reviewer says that the 
requested drugs is not medically reasonable or necessary. Our physician reviewer found this enrollee with 
metastatic prostate cancer remains has remained stable on leuprolide. Continuation with other therapy for 
urothelial cancer is reasonable and medically necessary. Nivolumab is not FDA approved, supported by major 
drug compendia or the medical literature for 1st line therapy for urothelial cancer whereas other PD-L1 
inhibitors are indicated for 1st line treatment in patients unfit for platin based therapy. The service is 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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve OPDIVO and Leuprolide Acetate for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery, an office visit, 
specialist office visits, and occupational therapy visits provided by participating providers on June 26, 2020, to 
October 16, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery, an office visit, specialist office visits, and 
occupational therapy visits. You say that you do not feel like you should pay for services that were provided 
because of your arm injury. The Plan denied your request. The Plan says the correct copayments have 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 $200 
copayment for outpatient surgery, a $10 copayment and a $40 copayment for physician/practitioner 
services/primary care physician and specialist and, a $40 copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $200 copayment for an outpatient surgery, a $10 copayment and a $40 
copayment for an office visit and specialist office visits, and occupational therapy visits. The total amount you 
are being asked to pay is $650 ($200 outpatient surgery + $10 office visit + $80 ($40 x 2 visits) specialist office 
visit + $400 ($40 x 10 visits) occupational therapy services). 
 
 
An outpatient surgery falls with the outpatient surgery benefit category, an office visit and specialist office 
visits fall within the physician/practitioner services/primary care physician and specialist benefit category, and 
occupational therapy visits falls within the outpatient rehabilitation 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 an outpatient surgery, an office visit, specialist office visits, and 
occupational therapy visits provided by participating providers on June 26, 2020, to October 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HETLIOZ. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 HETLIOZ.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 20, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 medical services provided on August 20, 2020, 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued skilled nursing facility (SNF) services beyond 
January 2, 2021. 
 
You asked the Plan to approve these services. You say that the enrollee needs more rehab. The Plan denied 
your request. The Plan says the continued services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to approve these services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on 
December 7, 2020 after hospitalization for a fall, urinary tract infection, and deep vein thrombosis. As of 
December 29, 2020 she needs minimal assistance with bed mobility and transfers. She was discharged from 
occupational therapy on January 4, 2021 as she often refused services. She does not have any skilled nursing 
needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, 
the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to approve continued skilled nursing facility (SNF) services beyond January 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Esomeprazole Magnesium. 
 
You asked the Plan to pre-approve Esomeprazole Magnesium. The Plan denied your request. The Plan says this 
medication does not fall under Part B benefits. 
 
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 Esomeprazole Magnesium.  
 
Benefits for Esomeprazole Magnesium 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D tissue analysis testing provided. 
 
You asked the Plan to pay for lab testing. You say that this testing is indicated in addition to endoscopy for 
patients with known or suspected Barrett's esophagus. The Plan denied your request. The Plan says the denial 
of payment for this testing is correct, because this testing is considered experimental/investigational. 
 
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 pay for lab testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found guidelines recognizing the low quality of available evidence in favor of application of this 
technique, suggest only conditionally that WATS 3D be reserved for cases of known or suspected Barrett's 
esophagus. The available records do not support high likelihood of Barrett's esophagus, and the enrollee's gold 
standard histology proved negative. In this case WATS 3D does not meet the spirit of American Society for 
Gastrointestinal Endoscopy (ASGE) guidance, and in fact the assay results proved more equivocal than 
traditional histology. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have 
to pay for WATS 3D tissue analysis testing provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Norco tab 10-325mg 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 this medication falls under Part D. 
 
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 Norco tab 10-325mg for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stay and the SNF 
stay provided from December 2, 2019 to January 23, 2020. 
 
You asked the Plan to waive the copayments for the inpatient hospital stay and the SNF stay. You say that you 
should not have to pay anything since the wrong diagnosis code was used and you were overcharged for your 
hospital stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 per day (per Medicare-covered stay) for days 1-5 for in-network inpatient hospital care, which 
includes day of admission and day of discharge. After the fifth day, the Plan pays 100% of the covered 
expenses. 
Your contract with the Plan clearly says that you must pay a $0 copayment per day (per benefit period) for days 
1-20 at an in-network SNF. There is a $160 copayment per day (per benefit period for days 21 to 100 at an in-
network SNF.  
 
You have been asked to pay a $1,475 copayment for the inpatient hospital stay. ($295 x 5 days = $1,475).You 
have been asked to pay a $3,520 copayment for the SNF stay from January 1, 2020 to January 23, 2020. ($160 
x 22 SNF days = $3,520). The inpatient hospital stay falls within the ?Inpatient hospital care? benefit category. 
The SNF stay falls within the ?Skilled nursing facility (SNF) 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 copayments for the inpatient hospital stay and the SNF stay provided from 
December 2, 2019 to January 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep study. 
 
You asked the Plan to pre-approve the sleep study. You say that you would like reconsideration because the 
member has shortness of breath and sleep apnea is a possibility. The Plan denied your request. The Plan says 
the member has no clinical signs of sleep apnea. 
 
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 sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the member has no documented symptoms or clinical signs of sleep apnea. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the sleep study.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialists visits to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
specialists visits to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2300, 
E2311, E2377, E2313, K0108). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the enrollee requires the 
above accessories. The medical records indicates you have "good" strength in the right upper extremity and 4-
4+/5 strength in the left upper extremity and she is mostly independent with dressing, grooming and eating. 
 
The medical records document that your upper extremity strength and function are adequate for the enrollee to 
be able to control the power options using their own switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional accessories for a power wheelchair (E2300, E2311, E2377, E2313, K0108).