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

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy performed on October 
9, 2021. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. You say that you feel that the 
copayment should be waived due to the waiting time and non-service. 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 $325 
copayment for each outpatient hospital facility visit.  
 
You have been asked to pay a $325 copayment for the cystourethroscopy. The cystourethroscopy falls within 
the Outpatient Surgery, Including 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 waive the copayment for a cystourethroscopy 
performed on October 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 5, 2021, to July 
28, 2021. 
 
You asked the Plan to pay for the home health services. You say that you were not aware of the Plan's 5 day 
rule for RAP submission. The Plan denied your request. The Plan says the RAP claim was submitted outside of 
the deadline date. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, July 5, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from July 5, 2021, to July 28, 2021.
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 enrollee is active in the community and is high 
functioning at baseline. You say that the enrollee was independent for all mobility and activities of daily living 
prior to hospital admission. You say that the enrollee is extremely motivated and has the ability to return home 
with good support after an intensive acute inpatient rehabilitation program. The Plan denied your request. The 
Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in 
another setting. 
 
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 documentation does not support that the complexity of the enrollee's nursing, 
medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day/5 days a 
week, or 15 hours over 7 consecutive days, of therapy services. While the enrollee is reasonably expected to be 
able to participate in and benefit from therapy services, they can be provided at 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra ophthalmic solution. 
 
You asked the Plan to pre-approve Xiidra. You say that this medicine has been working well for the enrollee's 
symptoms. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 
benefit. 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra ophthalmic solution.  
 
 
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
would likely be able to fully participate in a therapy program. Skilled therapy services may be provided at 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Northera. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Northera.  
 
 
 
  
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoes purchased on October 3, 2021. 
 
You asked the Plan to pay for these shoes. You say that you needed to purchase shoes right away. The Plan 
denied your request. The Plan says this provider is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by vendor who is not a Medicare eligible provider. You purchased shoes 
from a retail vendor who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have 
to pay for shoes purchased at Foot Locker on October 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care. 
 
You asked the Plan to pre-approve inpatient hospital care. You say that you need to try rehab due to fluids that 
have traveled to your feet and legs and nearly your heart. You are asking for assistance and your primary care 
physician (PCP) is not helping you with the referral. The Plan denied your request. The Plan says the requested 
inpatient hospital care does not meet criteria. 
 
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 inpatient hospital care. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were assessed by vascular surgery who recommended outpatient follow-up with 
use of a pump for your chronic lymphedema. You were digressed with improvement in your lower extremity 
edema during your stay. Imaging revealed sufficient arterial flow in lower extremities as well as no DVTs 
present bilaterally. You were educated on management of chronic lower extremity edema including appropriate 
use of compression stockings and Lasix. You were advised to follow a low sodium diet. You were determined 
to have reached maximal benefit of hospitalization, was discharged from hospitalist services and encouraged to 
follow up with your primary care provider within one week. Home healthcare was arranged prior to discharge. 
The review indicates that there is no indication for continued inpatient hospital 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 inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
January 14, 2021. 
You asked the Plan to pay for the hospital discharge day management (99239). You say that the patient's 
medical records warrant the service of more than one physician with distinct specialties as reasonable and 
necessary. You say that the medical records should be reviewed, and the claim reconsidered for payment. The 
Plan denied your request. The Plan says no modifiers are allowed with this code edit. 
 
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 99239 
is a column II code to column I code 99223. This claim cannot be billed with a 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 the hospital discharge day management (99239) provided on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme for the enrollee. 
 
You asked the Plan to pre-approve Feraheme. You say that this is medically necessary for the treatment of the 
enrollee's iron deficiency. The Plan denied your request. The Plan says that there is no indication their preferred 
drugs would likely be less effective, and/or cause adverse effects for the member. 
 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 Feraheme. Our reviewer says that 
Feraheme is not medically reasonable and necessary. The enrollee has iron deficiency anemia related to cancer. 
The requested medication is a new start. The provided records do not indicate that the enrollee has tried and 
failed Infed (iron dextran) and Venofer (iron sucrose). The record does not indicate that the enrollee has a 
contraindication to or would have an adverse effect from the plan's preferred alternatives. Our physician 
reviewer found that the enrollee's condition does not meet step therapy criteria for Feraheme. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 30, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is a misinterpretation of the guidelines. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 
  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
We looked at the file and the rules. If an independent lab bills for services, the place where the sample was 
taken is reported as the place of service. The records do not show that the specimen was obtained at an 
independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services 
provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on August 18, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the 
member must access their hearing aid benefit and get connected with a network provider by contacting the 
Plan's hearing vendor. 
 
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 the member accesses the hearing aid benefits by contacting the Plan's hearing vendor. 
 
We looked at the file and the Plan's rules. The file shows that you did not contact the Plans hearing vendor to 
access the hearing aid benefit. Based on this information, we decided that the Plan's rules for coverage of the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing 
aids provided on August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on October 19, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that the service at issue was a necessity 
for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 70450 
is a column II code to column I code 70496. 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 a computed tomography (CT) scan of the head or brain (70450) 
provided on October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint blocks (64493, 64494). 
 
You asked the Plan to pre-approve facet joint blocks. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested services 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 facet joint blocks. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is evidence of radiculopathy documented by electromyography. The enrollee does not 
meet coverage criteria for the requested facet joint injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet joint blocks (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cane purchased out of network on June 24, 2021. 
 
You asked the Plan to pay for this purchase. You say that the Plan should pay for this cane. The Plan denied 
your request. The Plan says you did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract says that 
durable medical equipment requires prior authorization. You did not have prior authorization for this purchase.  
Therefore, we decided that the Plan does not have to pay for a cane purchased out of network on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (64483) epidurography, radiological supervision and 
interpretation (72275) injection, dexamethasone sodium phosphate (J1100) infusion, normal saline solution 
(J7050) injection, ketorolac tromethamine (J1885) provided September 15, 2020. 
 
You asked the Plan to pay for the diagnostic services. You say that you have attached proof of timely filing and 
request for reprocessing of this claim for payment. You have attached all supporting documentation. The Plan 
denied your request. The Plan says the claim was submitted past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the injection services was not filed until October 8, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed.  Therefore, we decided that the Plan does not have to pay for injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (64483) epidurography, radiological supervision and 
interpretation (72275) injection, dexamethasone sodium phosphate (J1100) infusion, normal saline solution 
(J7050) injection, ketorolac tromethamine (J1885) provided September 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on April 16, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. If an independent lab bills for services, the place where the sample was taken is reported as the place of service. The records do not show that the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on October 8, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that your understanding is that you are entitled to a 
$500 allowance toward the cost of hearing aids. You only learned you had a hearing aid benefit after you made 
this purchase. The Plan denied your request. The Plan says hearing aids are only covered when they are 
purchased through the Plan's specified routine hearing vendor. The provider in this case is out-of-network, and 
therefore the hearing aids are not eligible for coverage. 
 
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 they are purchased from the Plans specified routine hearing vendor. 
 
We looked at the file and the Plan's rules. The hearing aids in this case were not purchased through the 
specified vendor group. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) 
purchased on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services (99000) provided August 27, 
2021. 
 
You asked the Plan to pay for the outpatient therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the code billed is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 We find that CPT code 99000 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, this code has a status of "B" and payment is always bundled with another service. Based on this 
information, we decided that Medicare rules for coverage of the outpatient therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for outpatient therapy services (99000) provided 
August 27, 2021.