Persius/hicric huggingface dataset:
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 the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity 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 available documentation does not support that the enrollee has a need for 
complex medical treatment in an LTACH. The enrollee does not require services at the LTACH that are not 
available at the acute-care hospital or the skilled-nursing 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM device 
(K0553) provided December 17, 2021. 
 
You asked the Plan to pay for the supply allowance for CGM. You say that the services were medically 
necessary and you are requesting reconsideration. The Plan denied your request. The Plan says there is no 
documentation of insulin use, therefore the enrollee does not meet the criteria. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the supply allowance for CGM have not been met. 
Therefore, we decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM 
device (K0553) provided December 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 7480 billed for date of service May 17, 2022. 
 
You asked the Plan to pay for procedure code 7480. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 7480 is bundled into payment for 
code 70450. 
 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 7480 is a column II code to column I code 70450. 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 7480 
billed for date of service May 17, 2022.
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 the requested LTACH care is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity 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 available documentation does not support that the enrollee has a need for 
complex medical treatment in a LTACH. The enrollee does not require services at the LTACH that are not 
available at the acute-care hospital or the skilled-nursing 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298 x2) received on January 3, 2022. 
 
You asked the Plan to pay for hearing aids. You say that you want the Plan to reimburse you for the hearing 
aids. The Plan denied your request. The Plan says hearing aids purchased out-of-network are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased form an in-network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Specifically, the hearing aids were purchased by an out-of-network 
provider, and therefore are not covered. Therefore, we decided that the Plan does not have to pay for hearing 
aids (V5298 x2) received on January 3, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the beneficiary does not require skilled nursing or therapy services on a daily basis. 
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis 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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda infusions. 
 
You asked the Plan to pre-approve Keytruda infusions. You say that the enrollee is unable to tolerate 
concurrent cytotoxic chemotherapy. You also say that Keytruda can be used as single agent therapy for this 
indication. The Plan denied your request. The Plan says the criteria for medical necessity have not been met. 
 
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 Keytruda infusions. Our reviewer says 
that Keytruda infusions are not reasonable and necessary. Our physician reviewer found the requested use of 
Keytruda is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug 
compendia or clinical research that appears in a Centers for Medicare & Medicaid Services approved medical 
journal. Our reviewer also found that the use is not listed as not indicated, not supported or not recommended 
in any of the compendia. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda infusions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Keytruda infusions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted suction suspension (VASS) system 
(L5781) for a prosthetic limb. 
 
You asked the Plan to pre-approve a VASS system. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules have not been met because the 
requested item is experimental/investigational. 
 
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 VASS system. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested item exceeds your medical needs and is not proven superior to a standard socket. The medical 
literature reviewed indicates that further research is needed with clinical trials that recruit larger sample sizes 
and report long-term outcome data for the requested item. 
 
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 VASS system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a VASS system (L5781) for a prosthetic limb.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard (J1569). 
 
You asked the Plan to pre-approve Gammagard. You say that the enrollee has successfully been treated with 
intravenous immunoglobin (IVIG) infusions without complications in the past. You also say that this treatment 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Gammagard. Our reviewer says that the 
requested drug, Gammagard, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the reviewer found that 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 Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gammagard (J1569).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for physical therapy visits provided on 
January 11, 2022, to January 20, 2022. 
 
You asked the Plan to reduce the copayment for physical therapy visits. You say that you did not know there 
were so many copayments for this treatment and cannot afford it. 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 $20 
copayment for outpatient rehabilitation services. 
 
 
 
 
 
 You have been asked to pay a $20 copayment for physical therapy visits. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. You had two visits ($20 copayment x 2 visits = $40). Therefore, we decided that 
the Plan does not have to reduce the copayment for physical therapy visits provided on January 11, 2022, to 
January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and testing (99214, 3078F, 3074F, 1126F) 
provided on June 3, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  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 office visit and testing (99214, 3078F, 3074F, 
1126F) provided on June 3, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve epidural steroid injection. You say that this procedure gives you some relief. 
The Plan denied your request. The Plan says you do not meet the Medicare coverage criteria for this epidural. 
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections are only covered if certain 
criteria are met.  
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 epidural steroid injection. Our reviewer 
says that you do not meet the Medicare criteria for an epidural steroid injection. Our physician reviewer found 
there is no documented percentage of pain relief from the prior epidural injections and you are not part of an 
active rehabilitation program, home exercise program, or functional restoration program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64625) for the sacroiliac joint. 
 
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the requested RFA 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 the RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of 
sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this 
procedure does not improve outcomes compared to standard treatment of SIJ pain. Therefore, the reviewer 
found that the requested RFA 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (64625) for the sacroiliac joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will need extensive therapy 
while continuing to receive acute care in a LTACH setting. The Plan denied your request. The Plan says the 
enrollee has not finished their full course of care in the hospital. The enrollee is not medically stable to transfer 
to another level of care. Therefore, admission to the LTACH is denied. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can be safely 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 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary at 
this time as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on April 
01, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you should not be 
responsible to pay this. 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 $275 
copayment for ambulance services. 
 
 
 
 
 
 
 You have been asked to pay a $275 copayment for ambulance transportation. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transportation provided on April 01, 2022.
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 need physical therapy to get back to normal 
living. The Plan denied your request. The Plan says your records do not show that you require these skilled 
services on a daily basis, nor that daily skilled services can be provided only on an inpatient basis in a SNF. 
The services you require can safely be received at a different setting, for example, home with home health, in 
residential care, or home with close follow-up with your doctor.  
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 are not shown to have an acute decline in function and you are functioning at a 
level commiserate with your amputation status. You do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
Our reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) 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.