Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy services (90832) provided from April 6, 2021, to May 
25, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment for 
psychotherapy services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have been met. Specifically, the record shows that the enrollee was referred 
to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay for 
psychotherapy services (90832) provided from April 6, 2021, to May 25, 2021.  
 
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: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from January 1, 2022, to January 10, 2022. 
 
You asked the Plan to pay for the inpatient stay. You say that services were medically necessary. The Plan 
denied your request. The Plan says that acute inpatient hospital care 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 supports the criteria for an inpatient stay. Our physician reviewer found that the 
records show that at the time of inpatient admission, the admitting physician reasonably expected that the 
enrollees hospital care would span two midnights. The enrollee was clinically unfit for discharge as he was at 
high risk for fall and dehydration. Inpatient treatment and care was not available in a lower care setting, 
warranting admission.  
 
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 been met. Therefore, we decided that the Plan 
has to pay for the inpatient stay provided from January 1, 2022, to January 10, 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 pre-approve a pneumatic compression device (PCD) with appliance 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that without this device the 
enrollee is at increased risk for infection and delayed wound healing. The Plan denied your request. The Plan 
says the denial of authorization for this device is correct, because this provider is out-of-network with the Plan 
and this item can be provided by an in-network equipment supplier. 
 
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 pneumatic compression device (PCD) with appliance to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the injection, Filgrastim-aafi, Biosimilar, (Nivestym), 1 microgram 
(Q5110) provided January 21, 2022. 
 
You asked the Plan to pay for the injection. You say that the items being appealed were approved on 
01/06/2022 for dates of service 01/01/2022 through 07/10/2022 and on 01/10/2022 for dates of service 
01/11/2022 through 07/11/2022. The Plan denied your request. The Plan says that this injection is not 
medically necessary. There is no documentation as to why the enrollee cannot continue Paclitaxel without 
Filgrastim-Aafi. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the injection. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found Peg-Filgastrim is indicated for the prevention of neutropenic fever in patients with >20% risk. This 
enrollee is deemed to meet these criteria. Medicare may cover a drug or biological if it is safe and effective and 
otherwise reasonable and necessary. The use of Filgrastim-aafi, Biosimilar, (Nivestym) meet the criteria. It is 
safe and effective and reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pay for 
the injection, Filgrastim-aafi, Biosimilar, (Nivestym), 1 microgram (Q5110) provided January 21, 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: 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 you require IRF care to improve movement. The 
Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need 
for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apnea monitor (E0618) provided on January 19, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an apnea monitor. You say that the in-network supplier could not supply the 
device at issue in a timely manner. The Plan denied your request. The Plan says rules for payment for OON 
care have not been met. 
 
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 an apnea monitor (E0618) provided on January 19, 
2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD) 
provided on January 10, 2022. 
 
You asked the Plan to waive the copayment for an EGD. You say that you should be charged for an ambulatory 
surgical center copayment, not an outpatient hospital facility copayment. The Plan denied your request. The 
Plan says the copayment applied was correct. The procedure happened in an outpatient hospital facility. 
 
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 $325 
copayment for same-day outpatient surgery in an Outpatient Hospital Facility.  
 
You have been asked to pay a $325 copayment for an EGD. An EGD falls within the Same-Day Outpatient 
Surgery in An Outpatient Hospital Facility benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an esophagogastroduodenoscopy (EGD) provided on January 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve speech therapy. You say that this service was previously approved by 
Medicare, and you do not really understand the denial. The Plan denied your request. The Plan says the 
services are not covered when provided by an OON 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 
speech therapy to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on December 21, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not have this copayment. 
The Plan denied your request. The Plan says the copayment applied was 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 $60 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $60 copayment for a CT scan. A CT scan falls 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 copayment 
for a computed tomography (CT) scan provided on December 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee. 
 
You asked the Plan to pre-approve the concentrator. You say that the enrollee has breathing problems and can't 
live without the oxygen tank. The Plan denied your request. The Plan says there is no evidence of any testing to 
determine blood oxygen saturation levels. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that home 
supplemental oxygen, including a portable oxygen concentrator, is not medically necessary. The enrollee has 
pulmonary fibrosis according to a recent chest computed tomography (CT) scan report. SpO2 during recent 
office visits have been 95 to 96%, presumably breathing room air.  There is no exercise oximetry. Oxygen need 
is not established. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(64628). 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve. You say that 
thermal destruction of intraosseous basivertebral nerve is medically necessary. The Plan denied your request. 
The Plan says thermal destruction of intraosseous basivertebral nerve 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 thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that thermal destruction of intraosseous basivertebral nerve is not 
considered medically reasonable and necessary. Our physician reviewer found this is considered an 
experimental/ investigational approach. Therefore, the request is deemed 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 thermal destruction of intraosseous basivertebral nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve (64628).
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 you need LTACH care. 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 that the there is no documentation provided indicating medical necessity for 
admission to an LTACH. In this case, the enrollee is an 82-year-old female admitted to acute hospital on July 
11, 2022, for a parieto-occipital intracranial hemorrhage with intraventricular hemorrhage complicated by 
hydrocephalus. She underwent an external ventricular drain (EVD) placement on July 17, 2022. Currently, as 
of August 1, 2022, it is noted that she is on 2 liters of oxygen and tolerating pureed diet and continuous tube 
feeds. 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 they are currently receiving care. 
The requested LTACH services 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF) 
care provided from January 14, 2022, through January 29, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $0 
copayment each day, for Medicare-covered days 1-20 and a $188 copayment each day, for Medicare-covered 
days 21-44 for skilled nursing facility care. Additionally, you pay a $0 copayment for additional Medicare-
covered days, up to 100 days. 
 
 You have been asked to pay $2,068 ($188 x 11 days) for the skilled nursing facility care provided. This 
copayment applied to days 21-32 of skilled nursing care provided as you previously received these services in 
the same benefit period in another facility, from November 17, 2021, through December 3, 2021 (days 1-17). 
The Plan contract states that you must pay a $0 copayment each day, for days 1-20 and a $188 copayment each 
day, for days 21-44 for skilled nursing facility care. 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 inpatient skilled nursing facility (SNF) care provided from January 14, 2022, through January 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found you may benefit from home BiPAP with the AVAPS mode, which has not been tried. Medicare 
does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).