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

 
We decided that the Plan does not have to pay for principal care management services provided on August 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. You say that the enrollee was in a nursing 
home setting and couldn't choose an in-network provider. The Plan denied your request. The Plan says the 
enrollee must receive care from 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 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 had network providers 
available who could have provided 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 principal care management services provided on 
August 19, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve an Orthovisc injection. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee did not have an injection in 
2022. The Plan denied your request. The Plan says that the enrollee does not meet the requirements for 
additional treatment. 
 
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. 
 
The Plan did not provide an applicable Medicare rule on which their denial was based on. The case file shows 
that medical records were not requested until after the case was forwarded to Maximus. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pre-approve an Orthovisc injection.  
 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will improve strength, endurance, 
balance, transfers, ambulation, activities of daily living, and safety to reduce risk of falls. You also say the 
enrollee and family will be educated in disease processes and recognize when to seek medical intervention. The 
Plan denied your request. The Plan says criteria for admission to the IRF 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 in the Medicare rules section. 
 
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 based on the limited documentation provided, 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says that the enrollee does 
not meet the Medicare criteria for admission to an LTACH care. The plan will continue to cover medically 
necessary acute and critical care at the current facility until the member's condition is stable for transfer to an 
alternate level of care (such as a skilled nursing facility), or until the clinical circumstances change such that 
LTACH may be reconsidered. 
 
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. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory insulin infusion pump. 
 
You asked the Plan to pre-approve an external ambulatory insulin infusion pump. You say that the records 
provided support the need for the item in dispute. The Plan denied your request. The Plan says the requested 
item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 
 
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 an external ambulatory insulin infusion 
pump. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
enrollee's C-peptide is 7.1 which is way above the 110% cutoff for insulinopenia. The glucose level 
requirement of less than 225 mg/dl is there to prevent a situation where glucose toxicity lowers the pancreatic 
production of endogenous insulin resulting in a picture suggestive of insulinopenia when the pancreas can 
actually make insulin. The fact that the blood glucose is above the 225 level is irrelevant here since the c-
peptide is high. The enrollee has type 2 diabetes mellitus (DM.) While the enrollee may benefit from an insulin 
pump, they do not meet the coverage criteria requirements. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external ambulatory insulin infusion pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external ambulatory insulin infusion pump.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service June 3, 2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this is not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 
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 have confirmed that code 76770 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76770 billed for date of service June 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 
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 have confirmed that code 76770 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76770 billed for date of service May 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
You asked the Plan to pre-approve Lupron Depot. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Lupron Depot. Our reviewer says that 
the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has prostate cancer. The documentation does not support that the enrollee has tried and 
failed Eligard. The documentation does not support that Eligard would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 5, 2022, 
to July 6, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says 
inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was evaluated with a history and physical exam, laboraotry studies, 
EKG and CXR. His EKG was without any acute ischemic changes; troponin was 56, CXR demonstrated 
atelectasis in the left lobe. He was admitted to telemetry. Echocardiogram revealed an EF 71% with no wall 
motion abnormalities. He was discharged home with outpatient follow-up on July 6, 2022. The record did not 
show that at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from July 5, 2022, to July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
May 21, 2022, to May 23, 2022.  
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be 
responsible to pay this because you were not told you would have a copayment. The Plan denied your request. 
The Plan says this cost sharing was charged 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 $220 
copayment per day, per admission for in-network hospital care for days 1 to 5, and a $0 copayment per day for 
days 6 to 90.  
 You have been asked to pay $440 for inpatient hospital care ($220/day x 2 days = $440). This item/service falls 
within the inpatient hospital 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 
inpatient hospital care provided from May 21, 2022, to May 23, 2022.
Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the bone/joint imaging. We also decided that the Plan 
does not have to waive the copayment for the ambulance services.  
 
You asked the Plan to waive the copayment for ambulance services and a bone/joint imaging study provided 
from May 3, 2022, to June 24, 2022. You say that the copayments are too high. The Plan says that this cost 
sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayment for the bone/joint imaging.  
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost-sharing information (such as copayments, deductibles, and coinsurance). The Plan says that you must pay 
a $50 copayment for diagnostic procedures and tests. Based on the Plan contract, however, you cannot be asked 
to pay more than a $40 copayment for advanced imaging services at an independent diagnostic testing facility 
(IDTF). Therefore, we decided that the Plan has to reduce the copayment for the bone/joint imaging to $40. 
 
We also decided that the Plan does not have to waive the copayment for the ambulance services. 
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost-sharing information (such as copayments, deductibles, and coinsurance). You have been asked to pay a 
$225 copayment for the ambulance services. This item/service falls 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. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transferring the enrollee to an LTACH is 
medically necessary for their medical needs. The Plan denied your request. The Plan says the enrollee is 
receiving the medical necessity care that they need in their current hospital. 
 
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. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the 
enrollee is not yet stable for transfer and as it would not be clinically advantageous. Completion of treatment at 
the current facility is recommended. 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: 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 an IRF will provide you with the services required to 
regain your strength and function independently. The Plan denied your request. The Plan says the IRF services 
you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, 
you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  
Your care needs can be met at a lower level of care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2310) and seat belt (E0978) 
for a power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and seat belt for the power wheelchair.. You say 
that these features are medically necessary. The Plan denied your request. The Plan says coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are medically necessary. 
Rules also state that a Column II is included in allowance for a corresponding Column I code when provided at 
the same time. 
 
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 expandable controller and seat belt 
for the power wheelchair.. Our reviewer says that the requested controller is not medically necessary. Our 
physician reviewer found the enrollee has adequate strength to operate standard switches on a power 
wheelchair. Code E0978 (seat belt) is included in the base wheelchair code. This code is not separately 
payable. 
 
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 expandable controller and seat belt for the power wheelchair. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2310) and 
seat belt (E0978) for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cytogenetic studies provided on March 22, 2022, by an OON 
provider. 
 
You asked the Plan to pay for cytogenetic studies. You say that your services were performed at the request of 
an in-network physician. The Plan denied your request. The Plan says the enrollee must receive care from 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 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 had network providers 
available who could have provided 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 cytogenetic studies provided on March 22, 2022, 
by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric evaluation (90792), provides on April 18, 
2022. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that the service was medically necessary. The 
Plan denied your request. The Plan says Original Medicare covers services while member is enrolled in 
hospice. 
 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 psychiatric evaluation (90792), provides on April 18, 
2022.