Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for knee injections performed from January 
4, 2022, to January 18, 2022. 
 
You asked the Plan to reduce the copayments for the injections. You say that you paid a $30 copayment at the 
times of service. You say that you do not understand the other charges. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $100 
copayment for surgery or other services at an outpatient hospital or ambulatory surgical center.  
 
You have been asked to pay a $100 copayment for each of the 3 injections, for a total of $300. The injections 
fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 reduce the copayments for knee 
injections performed from January 4, 2022, to January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a commode chair and oxygen equipment 
provided from September 14, 2021, to November 14, 2021. 
 
You asked the Plan to waive the coinsurance for the commode chair and oxygen equipment. You say that you 
should have been reimbursed under the QMB program. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 durable medical equipment (DME). 
 
 
 
 
 
 Item Allowed Amount 20% Coinsurance 
Commode Chair  September 14, 2021 $119.95 $23.99 
Oxygen Concentrator  September 14, 2021 $122.12 $24.42 
Portable Oxygen Machine  October 14, 2021 $20.53 $4.10 
Oxygen Concentrator  October 14, 2021 $122.12 $24.42 
Portable Oxygen Machine  November 14, 2021 $20.53 $4.10 
Oxygen Concentrator  November 14, 2021 $122.12 $24.42 
Total:  $105.45 
 
The file shows that the Plan determined you did not meet the criteria for the Qualified Medicare Beneficiary 
(QMB) program during these dates of service. Therefore, you have been asked to pay $105.45, which is 20% of 
the allowed amount for the commode chair and oxygen equipment. The commode chair and oxygen equipment 
fall within the Durable Medical Equipment (DME) and Related 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 a commode chair and oxygen equipment provided from September 
14, 2021, to November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary for limited mobility 
secondary to chronic pain. The Plan denied your request. The Plan says a less costly power operated vehicle 
has not been ruled out. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the clinical 
documentation states that the enrollee has the ability to use a manual wheelchair, but has poor tolerability due 
to low back pain, without mention of upper limb capabilities. Additionally, there is no mention of the ability to 
safely use the power wheelchair.  
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair for the enrollee.
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 without acute rehabilitation services the enrollee's 
ability to regain maximum function is jeopardized due to severity of conditions and medical diagnosis. The 
Plan denied your request. The Plan says rehabilitation needs do not require an intensive team approach and can 
be met in a less intensive setting of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the enrollee was admitted for surgical repair of a hip fracture after a fall 
complicated by a traumatic hematoma and hypertensive urgency. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral transforminal epidural steroid injection 
services. 
 
You asked the Plan to pre-approve bilateral transforminal epidural steroid injection services. You say that the 
enrollee needs the requested injections services because she is in pain that is debilitation and affecting her 
quality of life. You say that the records provided support the need for these requested injection services. The 
Plan denied your request. The Plan says the services being requested are not medically reasonable and 
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 bilateral transforminal epidural steroid 
injection services. Our reviewer says that bilateral transforminal epidural steroid injection services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has pain 
that radiates to her buttocks and hips. She takes Mobic for pain. Her magnetic resonance imaging (MRI) shows 
degenerative disc disease and spinal stenosis at L4-L5 as well as facet joint separation at L5-S1. She has had 
rehabilitation therapies. The symptoms reported do not correspond to L4-L5 lesions. Rather they correspond to facet mediated pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral transforminal epidural steroid injection services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bilateral transforminal epidural steroid 
injection services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's neurological deficits are 
increasing. The Plan denied your request. The Plan says the clinical value of allograft in the setting of lumbar 
fusion surgery has not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that the Plan has agreed to pre-approve an inpatient admission for an anterior lumbar fusion 
procedure. An Isto Biologics Sparc lumbar spine allograft was requested as part of the approved fusion surgery. 
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 requested services. Our physician 
reviewer found that Isto Biologics allograft remains experimental for use in spinal surgery. More research is 
needed to show its efficacy. Therefore, the request is considered not 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve allograft services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
approaches. The Plan denied your request. The Plan says experimental procedures are not covered by 
Medicare. 
 
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 requested services. Our physician 
reviewer found that the device is experimental. More research is needed to show safety and efficacy. Therefore, 
the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous stabilization device.
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 need this level of care. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
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 you were admitted for congestive heart failure. Medical problems are stable.  
 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 IRF. There are no complex nursing or rehabilitation needs. While 
you have a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the injection. You say that a referral is not needed for the service that was billed 
and would like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 injection provided on January 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care services and the hospital discharge 
day provided on December 9, 2021, to December 13, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent hospital care services and the hospital discharge day. You say 
that are appealing the denied claims. The Plan denied your request. The Plan says no prior authorization was 
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 did not pre-approve the 
subsequent hospital care services and the hospital discharge day. We found no exception that would require the 
Plan to pay for subsequent hospital care services and the hospital discharge day. The records provided for 
review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for subsequent hospital care services and the hospital discharge day provided on December 9, 
2021, to December 13, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on January 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that you were not aware the provider was out-
of-network, and you do not want to be charged for the service. The Plan denied your request. The Plan says no 
prior authorization was 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 did not pre-approve the 
annual wellness visit. We found no exception that would require the Plan to pay for the annual wellness visit. 
The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the annual wellness visit provided on January 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan provided no supporting evidence to deny payment for these 
services based on Medicare coverage criteria. Therefore, we decided that the Plan has to pay for the laboratory 
services provided on September 1, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the services needed can be provided at an alternate level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hernia repair (49560) provided on October 5, 2021. 
 
You asked the Plan to pay for the hernia repair (49560). You say that the outlined notes should be reviewed and 
CPT code 49560 reconsidered for payment. The Plan denied your request. The Plan says procedure code 49560 
would be considered inclusive to procedure code 51590. 
 
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 49560 is repair initial incisional or ventral hernia; 
reducible. 
 
We asked our coder 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 hernia repair (49560). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that a 
hernia repair is not separately reportable unless the hernia repair is performed at a different site through a 
separate incision. In this case, a separate incision was not performed. Therefore, this procedure would be 
inclusive to the primary procedure performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the hernia repair (49560) have not been met. Therefore, we decided that the 
Plan does not have to pay for the hernia repair (49560) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99310) provided on January 25 to 
February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network 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 nursing facility care 
(99310) provided on January 25 to February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was seen by multiple providers, and 
you would like the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 provided on February 3, 2022, by an 
out-of-network (OON) provider.