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

 
We decided that the Plan does not have to pay for Tempus xT Assay testing (81455) provided on May 27, 
2022. 
 
You asked the Plan to pay for Tempus xT testing. You say that this testing was medically necessary and 
reasonable for this enrollee. The Plan denied your request. The Plan says the diagnosis billed on this claim does 
not support the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of CPT code 81455. Any other diagnosis code not listed in the article paragraph does not 
support medical necessity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Tempus xT testing have not been met. Specifically, the diagnosis code billed on this claim is not included on the list of appropriate diagnosis codes to support the medical necessity of CPT code 81455. 
Therefore, we decided that the Plan does not have to pay for Tempus xT Assay testing (81455) provided on 
May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like to return to her prior level of 
function and needs aggressive therapy for three hours daily. The Plan denied your request. The Plan says the 
guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the 
services needed 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for endocarditis and hematuria. The enrollee's medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for IV infusion therapy provided on March 11, 
2022, to June 3, 2022. 
 
You asked the Plan to waive the copayment for IV infusion therapy. You say that your plan changed how much 
they cover for these services without notice. They used to have a $70 copayment and now you have to pay 20% 
coinsurance. 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 20% 
coinsurance for all drugs covered under Original Medicare and $50 copayment for each specialist visit for 
Medicare-covered service. 
 
  You have been asked to pay $2,015.25, for IV infusion therapy.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
March 11, 2022 IV infusion $3,172.19 20% $314.91 
April 8, 2022 IV infusion $3,172.88 20% $625.58 
May 6, 2022 IV infusion $3,172.88 20% $625.58 
June 3, 2022 IV infusion $3,172.88 20% $249.19 
March 11, 2022  
June 3, 2022 
Specialist visit $199.59 $50 x 4 $200 
TOTAL:    $2,015.25 
 
This IV infusion falls within the Medicare Part B prescription drugs and Physician/Practitioner services, 
including doctor's office visits 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 IV infusion 
therapy provided on March 11, 2022, to June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 28, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you cannot afford to pay this 
amount. 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 $45 
copayment for a specialist visit.  
 
You have been asked to pay $45 for a specialist visit. This item/service falls within the physician/practitioner 
services, including doctors office visits 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 a specialist visit provided on February 28, 2022.
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 requires close monitoring by 
a skilled professional to manage their pain. You say that the enrollee requires extensive physical and 
occupational therapy. The Plan denied your request. The Plan says a LTACH admission is not medically 
necessary, and the enrollee can receive the services they need in another 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. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care setting. 
 
   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an out-of-network specialist office visit on 
June 3, 2022. 
 
You asked the Plan to waive the deductible for an out-of-network specialist office visit. You say that this 
provider is in-network, and you should only be responsible to pay a $40 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. Your 
contract with the Plan says that there is a $750 deductible which applies a specialist office visit.  
 
The item or service you asked the Plan to waive the deductible for falls within the specialist office visit benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to an out-of-network specialist office visit. This cost sharing is a contractual 
obligation that had not been met at the time an out-of-network office visit was received on June 3, 2022.  
 
 
 
 
 
 Therefore, we decided that the Plan does not have to waive the deductible for an out-of-network specialist 
office visit on June 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept 
procedure) (64628). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure fills a treatment gap when 
adequate relief is not achieved from traditional conservative treatment. The Plan denied your request. The Plan 
says that the requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not indicate that the enrollee is not a candidate for 
surgery. The reviewer found that the requested procedure is reasonable and medically necessary for the enrollee 
based on currently published studies and Food and Drug Administration (FDA) approval for this clinical 
indication. Therefore, the reviewer found that the requested procedure is medically reasonable and necessary in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have been met. Therefore, we decided that the Plan has to 
pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) (64628).  
 
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 pay for the acute inpatient hospital care provided on September 4, 
2021, to September 14, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the required services could have been provided at a 
lower level of care. 
 
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 observation care statues would be more appropriate for the enrollee. 
 
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 on September 4, 2021, to September 14, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not safe going home as they have had 
a stroke and a brain bleed. You say that the enrollee needs physical therapy to help build their strength back up. 
The Plan denied your request. The Plan says a SNF admission is 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 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 require skilled nursing services. Although the enrollee 
requires skilled therapy services, they do not require daily skilled services on an inpatient basis. The records do 
not document a significant decline in the enrollees functional status to necessitate further daily inpatient 
skilled therapy 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of any joint of the upper 
extremity (73221). 
 
You asked the Plan to pre-approve an MRI of any joint of the upper extremity. The Plan denied your request. 
The Plan says that this service cannot be approved because the records do not show results of a face-to-face 
evaluation that support the requested study. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of any joint of the upper 
extremity. Our reviewer says that an MRI is reasonable and necessary. Our physician reviewer found this 
enrollee has x-ray findings of degenerative changes and a course of physical therapy. Positive empty can test 
on physical exam is suspicious for rotator cuff tear. Our reviewer found that the enrollee has had an intra-
articular steroid injection. Our physician reviewer also found that the enrollee meets all of the accepted criteria 
for an MRI of the right shoulder. 
 
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 MRI of any joint of the upper extremity have been met. Therefore, we 
decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of any joint of the upper 
extremity (73221).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that the orthosis is medically 
necessary. The Plan denied your request. The Plan says coverage rules have 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 the powered upper extremity orthosis. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested device has not been shown to be superior to other standard 
treatments for the medical condition. The studies do not indicate the MyoPro brace improves an individuals 
function or general health. 
 
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 powered upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are a fall risk and are deeply concerned you will 
break your hip. You say that you can regain your strength you need if admitted to a SNF. The Plan denied your 
request. The Plan says a SNF admission is not medically necessary, and your needs can be met at a lower level 
of care. 
 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 you do not require skilled therapy services. Although you require skilled therapy 
services, there are no current physical therapy or occupational therapy reports provided define your status with 
ambulation, transfers or activities of daily living or your current needs. There is no documentation that you 
require services on an inpatient basis, only in a skilled nursing facility setting. 
 
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 SNF care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided on May 12, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were referred on an emergency basis. 
The Plan denied your request. The Plan says that a separate reimbursement is not allowed. 
 
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. 
 
We looked at the file and the rules. The records show that on the date of service at issue, you were seen by two 
different providers of two different specialties, a neurosurgeon and an internist. The rules say to pay both visits 
if the physicians are in different specialties and the visits are billed with different diagnoses. 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 pay for the evaluation and management services 
provided on May 12, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment you purchased on January 12, 2022. 
 
You asked the Plan to pay for the oxygen equipment. You say that your booklet does not say that you cannot 
purchase oxygen equipment. The Plan denied your request. The Plan says purchase of oxygen equipment is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen and oxygen equipment is only covered as 
a rental item.  There is no purchase option. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for oxygen equipment you purchased on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and 
pelvis (74177). 
 
You asked the Plan to pre-approve a CT of the abdomen and pelvis. The Plan denied your request. The Plan 
says a CT abdomen and pelvis is not reasonable or medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the abdomen and pelvis. Our 
reviewer says that a CT of the abdomen and pelvis is not reasonable and necessary. Our physician reviewer 
found aside from lab work, no medical records, including physical exam or history, have been submitted in 
order to provide evidence of medical necessity of the requested CT of the abdomen and pelvis.  
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 CT of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and pelvis (74177).