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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says that the coverage criteria has 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 that you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on November 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 12, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
rendered on November 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient services and Part B drugs on 
November 04, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient services and Part B drugs. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 
charged is correct. 
 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% 
coinsurance for coinsurance for each Medicare-covered Part B drug. You must pay a $295 copayment for 
Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not 
limited to hospital or other facility charges and physician or surgical charges. 
 
The provider billed in the amount of $676.00 and the allowed amount is $74.30. The is less than the copayment 
amount of $295. The provider billed in the amount of $1,008.00 and the allowed amount is $288.64.  $288.64 x 
20% = $57.73. The provider billed in the amount of $1,628.00 and the allowed amount is $115.12. $115.12 x 
20% = $23.02. The provider billed in the amount of $34,421.40 and the allowed amount is $5,879.60. The 
annual out-of-pocket maximum was met and are only held liable for $529.26. $74.30 + $57.73 + $23.02 + 
$529.26 = $684.31. Therefore, results in the total cost sharing amount of $684.31. 
 
You have been asked to pay a 20% coinsurance for Prat B drugs and a $74.30 copayment, which is less than 
the copayment for outpatient services. Outpatient services and Part B drugs fall within the Medicare Part B 
prescription drugs and Outpatient surgery and other medical services provided at hospital outpatient facilities 
and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
outpatient services and Part B drugs on November 04, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 5, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of FoundationOne CDx to the 
enrollee is medically necessary for the management of the enrollee's advanced cancer. The Plan denied your 
request. The Plan says the enrollee does not meet the guidelines for this service to be determined to be 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per the cited NCD, Next Generation Sequencing is considered to be medically 
necessary for somatic (acquired) cancer when the patient has either recurrent, relapsed, refractory, metastatic, 
or advanced stage III or IV cancer. The specimen sent for testing was obtained at the initial diagnostic biopsy. 
As the enrollee had had no cancer treatment, the tumor could not be recurrent relapsed, or refractory to 
treatment. There is no indication that he had had a metastatic staging work-up and given the time frame when 
the sample was sent for testing it would not have been possible for this time of work- up to be completed. The 
review has determined that the records did not support that the enrollee meets the medically necessary criteria 
for Medicare coverage as listed in the NCD. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Orthosis. 
 
You asked the Plan to pre-approve a MyoPro Orthosis. You say that the requested MyoPro Orthosis is 
medically necessary. The Plan denied your request. The Plan says the requested MyoPro Orthosis 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 a MyoPro Orthosis. Our reviewer says 
that the requested MyoPro Orthosis is not medically necessary. Our physician reviewer found based on the 
medical records provided and the current peer-reviewed medical literature there is no documentation that the 
MyoPro robotic brace at issue in this case meets all Medicare criteria for medically reasonable and necessary 
per Social Security Act, Section 1862(a)1(A). Current clinical guidelines designate robotic therapy to be of 
"uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven 
benefit in the home environment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro Orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Orthosis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is going to require significant assistance 
in care and skilled nursing is the best level of care at this time. The Plan denied your request. The Plan says 
based on Medicare guidelines, the requested SNF services do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. There are no services offered at a SNF that are not offered at an inpatient rehab facility. 
Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve an ESI. You say that the injection is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested injection is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when radiculopathy, radicular pain and/or neurogenic claudication is 
severe enough to greatly impact quality of life or function. 
 
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 ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found there is no documentation of 
radiculopathy, radicular pain and/or neurogenic claudication severe enough to greatly impact the enrollee's 
quality of life or function. Therefore, the reviewer found that the requested ESI is not medically reasonable or 
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 an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the microprocessor control unit (Q0481) and battery (Q0506) 
provided on April 12, 2022. 
 
You asked the Plan to pay for codes Q0481 and Q0506. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The rules say for DMEPOS claims, the place of service is considered 
to be the place where the enrollee will primarily use the DMEPOS item. In this case, the enrollee's home is the 
correct place of service. The Plan will accept a corrected claim for review. Therefore, we decided that the Plan 
does not have to pay for the microprocessor control unit (Q0481) and battery (Q0506) provided on April 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services and drugs you received on November 
11, 2021, and November 12, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered when provided out of the country. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The provider in question is located outside the United States and the services were not emergent. 
Therefore, we decided that the Plan does not have to pay for the surgery services and drugs you received on 
November 11, 2021, and November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 13, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider determined it was 
medically necessary to have the testing done and you would like reimbursement for the services rendered. The 
Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 the laboratory services provided on November 13, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on March 31, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you should be reimbursed for 
these tests. The Plan denied your request. The Plan says these COVID-19 tests were purchased without a 
prescription. The Plan also says these tests are not covered under Medicare or the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kits are an OTC item. The Plan does not offer a supplemental benefit covering this service, as 
this is not currently required by Medicare. However, for future purchases, these can be obtained with 
participating providers and covered by Original Medicare when using your Medicare card rather than your Plan 
card. Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, 
we decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on March 31, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor for long-term hemodynamic monitoring (33289) and implantable wireless pulmonary artery 
pressure sensor with delivery catheter, including all system components C2624). 
 
You asked the Plan to pre-approve the CardioMEMs heart monitor device. You say that you feel that the 
services are medically necessary, and the records should support the necessity of the services. The Plan denied 
your request. The Plan says there is not enough medical literature that shows this is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for overage of the CardioMEMs heart monitor device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery pressure 
sensor for long-term hemodynamic monitoring (33289) and implantable wireless pulmonary artery pressure 
sensor with delivery catheter, including all system components C2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage of 
acupuncture treatment. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the requested acupuncture treatment have not been met.  
 Specifically, the record does not show that you have requested acupuncture services for the treatment of 
chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture 
treatment.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77063 billed for date of service November 
16, 2021. 
 
You asked the Plan to pay for procedure code 77063. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 77063 is bundled into payment for code 77066.  
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 77063 
is a column II code to column I code 77066. 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 77063 billed for date of service November 16, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair and accessories coded as 
K0861, E2361, E1028, E2377, E2313, E1007, E2620, K0108, E2311, E1012, and E2609. 
 
You asked the Plan to pre-approve the power wheelchair. You say that due to the enrollee's impairments, you 
request an appeal and reconsideration of the original recommendation for a power chair with power seating and 
custom seating. The Plan denied your request. The Plan says the enrollee does not meet the criteria as the 
records do not show that the enrollee has an underlying medical condition or qualifying diagnosis for the 
requested Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve 
the Group 3 power wheelchair and accessories coded as K0861, E2361, E1028, E2377, E2313, E1007, E2620, 
K0108, E2311, E1012, and E2609.
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 meets LTAC admission 
criteria and ongoing medical needs warrant this level of care to achieve a safe and sustainable discharge. The 
Plan denied your request. The Plan says based on Medicare guidelines, the long term acute care hospital 
services you are requesting do not meet the requirements for approval. 
 
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 was admitted to the acute care hospital with COVID-19 pneumonia, 
pulmonary embolism, acute renal failure, dehydration, requiring high flow oxygen support, antibiotics, fluids, 
anticoagulation, bronchodilators, and steroids. The course was complicated by gastrointestinal bleed related to 
the anticoagulation treatment. Recent notes describe the enrollee as tolerating weaning but still dependent on 
high flow oxygen support.  
 The enrollee appears to be improving and should only require short-term additional acute care services that can 
safely be administered 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 available at the current 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable by 
Medicare Advantage plans. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
In this case, the enrollee not transported by ambulance. The ambulance benefit is a transportation benefit. 
When there is no transport, neither Medicare nor the Plan pays for the services provided. These services are not 
covered under the ET3 Telehealth program by Medicare Advantage plans. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided on March 24, 2022.