Persius/hicric huggingface dataset:
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 you need the more aggressive treatment 
that the LTACH provides so that you can go home. The Plan denied your request. The Plan says the criteria for 
LTACH admission were not met and the enrollee's medical needs are being met in the current acute 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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
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 health plan has approved ongoing care in the current acute care 
setting.  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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for you. The 
Plan denied your request. The Plan says step-therapy rules for the requested drug have not been met. 
 
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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of an intravenous bisphosphonate before they will approve the requested drug, Prolia. 
There is no indication that you have tried and failed the required drugs. Based on the medical records provided 
and the Medicare-approved major drug compendia, there is no indication that the Plan's required drugs 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 appears to be improving but is somewhat unstable and requires 
additional short term acute care services that can be safely administered at the current facility until more stable 
and appropriate for a lower level of care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231, 99232), and hospital 
discharge day management (99239) provided from March 20, 2022, to March 31, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was not enrolled in the hospice 
benefit from March 20, 2022, to March 29, 2022. You also say that the services rendered on these days should 
be paid. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99231, 99232), and hospital discharge day management (99239) provided from March 20, 2022, 
to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing billed for services provided on March 
8, 2022. 
 
You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says it cannot be 
determined how the enrollee came to the servicing provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. In this case, the billed services are not supported. There are no 
records from the treating physician. There is no order form or lab results for the billed service. The Plan made 
multiple attempts to obtain additional information, without success. Based on this information, we decided that 
the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory testing billed for services provided on March 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for inpatient surgery provided on May 12, 
2022, to May 14, 2022. 
 
You asked the Plan to reduce the copayment for inpatient surgery. You say that you should have to pay $245, 
this is the amount the Plan quoted you 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 $750 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $750 copayment for inpatient surgery. This item/service falls within the Inpatient 
hospital care 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. The copayment amount is $375/per day x 2 days = $750. Therefore, we decided that the Plan does not 
have to reduce the copayment for inpatient surgery provided on May 12, 2022, to May 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable cardiac rhythm monitor. 
 
You asked the Plan to pre-approve implantable cardiac rhythm monitor. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ILR is only covered for certain indications. 
 
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 implantable cardiac rhythm monitor. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee has a history of a stroke. The enrollee had no history of 
atrial fibrillation, nor were any significant cardiac arrhythmias noted on electrocardiogram monitoring. A 
recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed 
by treatment with oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in 
reducing stroke or systemic embolism among patients at high risk of stroke but without a known prior history 
of atrial fibrillation. At this time, insertion of an ILR would not be considered medically appropriate and 
necessary in this patients clinical management. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable cardiac rhythm monitor have not been met. Therefore, we decided 
that the Plan does not have to pre-approve implantable cardiac rhythm monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC). 
 You asked the Plan to pre-approve LAAC placement. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that placement of a LAAC is only covered for certain 
indications. 
 
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 LAAC placement. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has a history of atrial fibrillation. There is felt to be an elevated risk of 
thromboembolic stroke due to atrial fibrillation and CHADS2VASC score of two. There is no contraindication 
to anticoagulation according to the physician. As such, guidelines would not support implantation of a LAAC 
in this setting. In summary, LAAC placement would not be considered reasonable or medically necessary in 
this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of a left atrial appendage closure device (LAAC).
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 prolonged and 
intensive skilled services that are not available at a lower level of care. The Plan denied your request. The Plan 
says the criteria for admission to the LTACH 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 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 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 copayment for a chiropractic manipulative treatment 
provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for a chiropractic manipulative treatment. You say that the Plan 
paid nothing and your copayment is $20. You say the amount of the charge over should be covered according 
to the terms of the policy. 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 $75 
copayment for each out-of-network Medicare-covered visit.  
 
You have been asked to pay $29.92, which is less than the standard $75.00 copayment for a chiropractic 
manipulative treatment. This item/service falls within the Chiropractic 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 a chiropractic manipulative treatment provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trimming of nails (G0127) every 42 days. 
 
You asked the Plan to pre-approve routine podiatry service. You say that your nails grow more rapidly than 
normal. You say that at 42 days, your nails begin to catch on clothing and bedding, and begin to be painful 
when walking. You also say that your doctor advised you should not have your nails treated by a non-medical 
service. The Plan denied your request. The Plan says the requested routine foot care exceeds the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Routine foot care is limited to every 60 days. Based on this 
information, we decided that Medicare rules for coverage of routine podiatry service have not been met. 
Therefore, we decided that the Plan does not have to pre-approve trimming of nails (G0127) every 42 days.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Guided Focused Ultrasound 
Surgery (0389T). 
 
You asked the Plan to pre-approve the Magnetic Resonance Guided Focused Ultrasound Surgery. You say that 
this service is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage of Magnetic Resonance Guided Focused 
Ultrasound Surgery System (MRgFUS) for the treatment of neurologic conditions can be considered as an 
alternative when Deep Brain Stimulation (DBS) is not available or appropriate for the patient. 
 
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 Magnetic Resonance Guided 
Focused Ultrasound Surgery. Our reviewer says that the requested procedure is not medically necessary. Our 
physician reviewer found the enrollee has essential tremor and was deemed a candidate for DBS. This 
procedure can be considered for coverage only when the enrollee is not a candidate for DBS. 
 
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 Magnetic Resonance Guided Focused Ultrasound Surgery have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Guided Focused 
Ultrasound Surgery (0389T).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
February 26, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay $90 for an emergency room visit. This item/service falls within the emergency 
room visit 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 emergency room visit 
provided on February 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rental for portable gaseous oxygen system (CPT code 
E0431) and oxygen concentrator (CPT code E1390). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says servicing of the equipment is the responsibility of the DME company. The Plan must 
follow Medicare rules. We looked at the file and Medicare rules. Review of the information shows that the 
enrollee received this equipment in March 2019, and all thirty-six (36) rental payments have been made. You 
are beyond the 36-month rental allowance, leaving servicing of the equipment at the responsibility of the DME 
company. Therefore, we decided that the Plan does not have to pre-approve rental for portable gaseous oxygen 
system (CPT code E0431) and oxygen concentrator (CPT code E1390).
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 enrollee currently meets criteria for 
LTACH care. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been 
met. The enrollee's medical needs are being met in the current acute 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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
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. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac contractility modulation system (0408T, 
C1824). 
 
You asked the Plan to pre-approve the cardiac contractility modulation system. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says the requested procedure is experimental at 
this time and is non-covered. 
 
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 cardiac contractility modulation 
system. Our reviewer says that the requested services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found while clinical studies have supported FDA approval of the cardiac 
contractility modulation system, at this time more long-term, peer-reviewed studies are needed to show long 
term safety and benefit of this system. 
 
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 cardiac contractility modulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a cardiac contractility modulation system (0408T, C1824).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0427) and 
ground mileage (A0425) provided on April 5, 2022. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
would like this claim to be reprocessed for payment in full. The Plan denied your request. The Plan says the 
services rendered fell on a date when the enrollee elected Hospice during the month of April 2022. The Plan 
also says that this claim was processed correctly as Medicare-Fee-For-Service. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency ambulance transportation (A0427) and ground 
mileage (A0425) provided on April 5, 2022.