Persius/hicric huggingface dataset:
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 is motivated to improve. The Plan 
denied your request. The Plan says the enrollee does not need close physician monitoring. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for congestive heart failure, pneumonia, tricuspid valve 
repair, anoxic brain injury, and critical illness myopathy. His medical problems are stable. The complexity of 
his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vision care visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON vision care. You say that you would prefer to see this provider for 
more specialized care. The Plan denied your request. The Plan says out-of-network care is covered only in 
certain limited circumstances. The care you need is not urgent or emergent and can be performed by an in-
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 
a vision care visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on January 13, 20222. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 71045 is a column II code to column I code 32555. 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 x-ray services provided to the enrollee on January 13, 20222.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown restoration for tooth 11. 
 
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 the services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers these services 
when the services are medically necessary and reasonable.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation shows that there is 
less than 50 percent bone support of tooth 11. The prognosis of retention is poor. The documentation does not 
support that the coverage for a crown restoration for tooth 11 meets the Plan's criteria and is medically 
necessary due to the poor bone support.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a crown restoration for tooth 11.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Panitumumab and Pembrolizumab. 
 
You asked the Plan to pre-approve Panitumumab and Pembrolizumab. You say that these drugs are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested drug 
combination is not approved for treatment of colon cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Panitumumab and Pembrolizumab. Our 
reviewer says that the requested drugs are not medically reasonable and necessary. Our physician reviewer 
found that the record indicates that the enrollee has a diagnosis of metastatic colorectal cancer.  The Food and 
Drug Administration has not stated that the requested drug regimen is indicated for the enrollee's condition. 
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug regimen in the enrollee's clinical situation. No literature from Medicare approved cancer journals were 
submitted for review. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Panitumumab and Pembrolizumab have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Panitumumab and Pembrolizumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from May 
13, 2022, forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care.. You say that inpatient 
psychiatric care continues to be medically necessary. The Plan denied your request. The Plan says the criteria 
for coverage of inpatient psychiatric care are no longer met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient psychiatric 
care. Our reviewer says that the continuation of inpatient psychiatric care is not medically reasonable and 
necessary. Our physician reviewer found this 93-year-old female was admitted to the acute inpatient psychiatric 
hospitalization on May 2, 2022, with major neurocognitive disorder, unspecified without behavioral 
disturbance. Based upon review the records provided it was not expected this enrollee would improve in a 
reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and 
no auditory or visual hallucinations. This patient did not show any abnormal behaviors or any symptoms which 
would require acute treatment. It did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she 
did not have dangerousness to self or others but was compliant with her treatment with encouragement. 
 
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 continuation of inpatient psychiatric care. have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from May 13, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses (V2025, V2020, V2781). 
 You asked the Plan to pre-approve eyeglasses. You say that you lost your last pair when you were evicted from 
your home, and you need new eyeglasses. The Plan denied your request. The Plan says you previously used 
your full eyewear benefit on February 4, 2022. Your benefit covers prescription eyewear once every year. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $1,000 once every year. 
 
We looked at the file and the Plan's rules. The record shows that you have already used and exhausted your 
eyewear benefit in 2022. Based on this information, we decided that the Plan's rules for coverage of eyeglasses 
have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses (V2025, 
V2020, V2781).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Orthovisc (Current Procedural Terminology (CPT) 
code J7324). 
 
You asked the Plan to pre-approve the medication. You say that you have too many health conditions to worry 
about or be concerned about what knee injection you are given. The Plan denied your request. The Plan says 
the documentation received did not advise that at least one of the preferred products (Euflexxa, Synvisc, or 
Synvisc One) had been ineffective, not tolerated or is contraindicated or not a treatment option. 
 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 the medication. Our physician reviewer 
found there is no indication that you have tried and failed the required drug(s). The medical records provided 
there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse 
effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Orthovisc (Current Procedural Terminology (CPT) code J7324).
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 LTACH care is medically reasonable 
and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 
have not been met. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. The requested LTACH service are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from 
September 15, 2021, to November 5, 2021. 
 
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 
applied correctly based on the services provided. 
 
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 Outpatient diagnostic tests and therapeutic services and supplies.   
You have been asked to pay a 20% coinsurance for the radiation therapy services. Radiation therapy services 
fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 radiation therapy services provided from September 15, 2021, to 
November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on August 6, 2021. 
 
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided on August 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits (97110) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON physical therapy services. You say that this is the same provider who 
is also at an in-network facility. The Plan denied your request. The Plan says out-of-network care is covered 
only in certain limited circumstances. The requested therapy is not urgent or emergent, and there are several in-
network providers in your area who can provide this 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 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 
physical therapy visits (97110) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on December 10, 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 procedure code 52240 is not supported. 
 
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 52240 is cystourethroscopy, with fulguration (including 
cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s). 
 
We find that CPT code 52240 is not supported in the medical record. Specifically, the records show that 
cystourethroscopy with fulguration and/or resection of bladder tumor was performed but there is no 
documentation of the size of the tumor resected. There is a more appropriate code for these services. 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 pay for the surgical services rendered on December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) 
provided on January 26, 2022. 
 You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 
and 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 the computed tomography (CT) of the head or brain (70450) 
provided on January 26, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an electrocardiogram (EKG) provided on January 
31, 2022. 
 
You asked the Plan to waive the coinsurance for the EKG. You say that the amount is high for the service that 
was provided. The Plan denied your request. The Plan says that the coinsurance was applied for the entire 
claim and was processed correctly. 
 
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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan acknowledged that the coinsurance was being charged for the entire 
bill and not just for the EKG. The Plan failed to provide a specific allowed amount for the EKG. Also, the Plan 
has failed to provide an itemized claim or bill showing all the different items or services that were bundled into 
the individual line-item payment. Without this, we cannot determine if the Plans assessment of the coinsurance 
is correct. Therefore, we decided that the Plan has to waive the coinsurance for an electrocardiogram (EKG) 
provided on January 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NuVasive Osteocel allografts (CPT code(s): 20931 and 
20930). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the NuVasive Osteocel Allograft in the setting of 
anterior cervical spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the requested NuVasive Osteocel Allograft in the setting of anterior cervical spine 
fusion, in this case, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve NuVasive Osteocel allografts (CPT code(s): 20931 and 20930).