Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve joint shoulder surgery. 
 
You asked the Plan to pre-approve joint shoulder surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 joint shoulder surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. The request for left shoulder surgery 
including repair of tendons of shoulder, open procedure (23412); anchoring of biceps tendon (23430); and 
complete replacement of the shoulder joint (23472) 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 joint shoulder surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve joint shoulder surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from October 19, 
2019 to October 23, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of DRG 280 and primary diagnosis code 
J96.02. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 280 (acute myocardial infarction, discharged 
alive with mcc) and primary diagnosis code J96.02 (acute respiratory failure with hypercapnia). 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 these services. Our reviewer says that the submitted records 
do not support the billing of DRG 280 and primary diagnosis code J96.02. Our physician reviewer found the 
enrollee presented with severe acute respiratory distress with initial oxygen saturations in the 60-70s and 
labored respirations. He required supplemental oxygen via non-rebreather mask initiated by emergency medical 
services. While both acute chronic obstructive pulmonary disease (COPD) and mild congestive heart failure 
(CHF) were documented on admission, acute hypercarbic respiratory failure with a blood pH of 7.03 
constitutes a life-threatening condition, which necessitated non-invasive ventilatory assistance, additional 
monitoring, supplemental oxygen, and anticholinergic, beta-adrenergic agonist administration. Additionally, 
the medical record clearly indicated the reason for both presentation to the hospital and admission was due to 
hypercarbic respiratory failure. The records therefore do not support the billed DRG and primary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from October 19, 2019 to October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $25 copayment charged for a specialist visit with the 
Florida Cancer Specialists on July 20, 2021. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is contractual obligation. 
 
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 $25 
copayment for telehealth specialist services. 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 $25 copayment 
charged for a specialist visit with the Florida Cancer Specialists on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the photochemotherapy provided on August 21, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the photochemotherapy. You say that the authorization was cancelled. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the photochemotherapy provided on August 21, 2020, by an out-
of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound you had at an 
outpatient hospital facility on August 4, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you did not know a copayment 
would apply for this service. The Plan denied your request. The Plan says you were charged this copayment 
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 $50 
copayment for ultrasounds in an outpatient hospital setting.  
 
 You have been asked to pay a $50 copayment for the ultrasound. 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 abdominal ultrasound you had at an outpatient hospital facility on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiovascular genetic panel (81401, 81403, 81404, 81406, 
81406, 81479) provided on December 30, 2020. 
 
You asked the Plan to pay for a cardiovascular genetic panel. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not covered. The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a cardiovascular genetic 
panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular genetic 
panel (81401, 81403, 81404, 81406, 81406, 81479) provided on December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medtronic Infuse Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Medtronic Infuse 
Allograft in the setting of anterior cervical spine fusion surgery has not been demonstrated in the peer-reviewed 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Infuse is not FDA 
approved for use in the anterior cervical spine. Also, high complication rates have been reported with previous 
use. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Medtronic Infuse Allograft for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on June 16, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied 
your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, non-
emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our 
physician reviewer found that upon the ambulance arrival, the enrollee stood up and walked over and sat on the 
cot. There was no documentation of the enrollee not being able to be safely transported in a wheelchair. The 
review has determined that the documentation did not support that other means of transport (such as stretcher 
van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on June 16, 2021. The documentation did not support that the enrollee needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on 
June 16, 2021. The documentation did not support that the ambulance transport on June 16, 2021 was 
medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport (A0428, A0425) provided on June 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 
12, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this transport was set up 
by the rehab facility due to a fall. You said that in fairness, you should not be responsible for this bill. The Plan 
denied your request. The Plan says you were charged this copayment 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 $175 
copayment for ambulance services.  
 
You have been asked to pay a $175 copayment for the ambulance services. This copayment applies regardless 
of the reason for the transport. 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 services you 
received on April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The 
Plan denied your request. The Plan says a SNF admission is not medically necessary. 
 
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 
daily skilled services are not medically necessary. Our physician reviewer found that you have stabilized 
medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled 
therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing 
facility. You do not have any parental medication; or daily complex wound care. You are medically stable 
without any acute exacerbations of chronic medical problems. Your physical function is at or near your new 
baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled 
rehabilitation services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is adequate left upper extremity strength, and therefore the use of an 
expandable controller for the standard joystick is not required. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the enrollee requires other types of proportional input 
devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-
proportional input devices (e.g., sip and puff, head array, etc). The enrollee does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The enrollee's strength in the upper extremities supports that the enrollee can 
control any power options through their own individual switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for your 2020 health club membership fees. 
 
You asked the Plan to pay for the membership fees. You say that you were unable to submit your form on time. 
The Plan denied your request. The Plan says that your request was not submitted timely. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan requires 
reimbursement requests for your wellness allowance to be submitted by March 31st of the following year. 
 
The Plan's rules for coverage of gym benefits have not been met because you submitted your request for 
reimbursement on July 26, 2021, which is after the March 31st deadline. Therefore, we decided that the Plan 
does not have to pay for your 2020 health club membership fees.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the circulating tumor cell (CTC) testing provided on October 
29, 2020. 
 
You asked the Plan to pay for the circulating tumor cell (CTC) testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CTC testing is non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the circulating tumor cell (CTC) testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the circulating tumor cell (CTC) testing provided on October 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Feraheme infusions. 
 
You asked the Plan to pre-approve the Feraheme infusions. You say that you would like reconsideration 
because you have been taking over-the-counter iron supplements but your levels continue to drop. The Plan 
denied your request. The Plan says your last reported hemoglobin does not appear consistent with a failure of 
oral iron supplementation. 
 
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 pre-approve the Feraheme infusions. Our reviewer 
says that there is no specific clinical rationale for the requested medication. Our physician reviewer found the 
documentation does not support that the Feraheme infusion is medically reasonable and necessary. The 
documentation does not support that the Feraheme infusion will be safe and effective for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Feraheme infusions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Feraheme infusions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy 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: Surgery
Decision: Favorable

We decided that the Plan has to pay for the removal of a skin lesion provided on May 20, 2020, by an innetwork
provider.
You asked the Plan to pay for the service. You say that you have a raging infection on your back and the
dermatologist took you in and started scraping your back because you were in fear of the infection spreading.
The Plan denied your request. The Plan says that before you receive services from a specialist you must first
obtain a referral from your primary care physician.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the service by a contract provider. The file does not show that the Plan provided notice
that the service would not be covered. Under Medicare rules, this means the service is considered approved by
the Plan. The Plan states the dermatologist is contracted. Therefore, we decided that the Plan has to pay for the
removal of a skin lesion provided on May 20, 2020, by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services coded 11043 provided on 
December 15, 2020.  

You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 11043 
for the debridement services is a column II code to column I code 20670. This claim has not been billed with 
an appropriate modifier to bypass the edit. While code 11043 was billed with modifier 59, the documentation 
does not support that the service billed with the -59 modifier is a distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the debridement services coded 11043 provided on December 15, 2020.