Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from February 27, 
2022, to March 3, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
clinical information supports the diagnosis code and DRG assignment. The Plan denied your request. The Plan 
says DRG 872 is not supported as the diagnosis of Sepsis due to streptococcus. 
 
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 principal diagnosis code, A40.1, defined as Sepsis 
due to streptococcus, group B. 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 the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the medical records do not support the 
billing of Sepsis due to streptococcus, group B with DRG 872. Our physician reviewer found the enrollee is a 
42-year-old female who presented to the hospital with symptoms of a urinary tract infection (UTI). The 
enrollee had a low-grade fever, was alert and oriented, with abdominal tenderness, urine analysis positive for a 
UTI without signs of pyelonephritis, normal kidney function and stable blood pressure. Our reviewer found that 
Sepsis 3 criteria was not met based on the provided documentation. Our physician reviewer also found that 
although concern for possible development to sepsis was reasonable, there was insufficient evidence of sepsis 
during this hospitalization.  
 
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 provided from February 27, 2022, to March 3, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0427) and ground mileage 
(A0425) provided on July 29, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that the 
enrollee was transported from their home address to the hospital, and was not an inpatient at this time. The Plan 
denied your request. The Plan says that these services are not paid separately when the enrollee is an inpatient. 
 
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. The Plan is denying these services based on the enrollee being inpatient status. 
The ambulance report clearly shows the enrollee was not inpatient status, because the enrollee was picked up 
from their home and transported to the hospital for treatment. Therefore, the Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for the emergency ambulance transportation 
(A0427) and ground mileage (A0425) provided on July 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery spinal injection 
provided on August 18, 2021. 
 
You asked the Plan to waive the copayment for spinal injection. You say that you did not know that there 
would be a $300 copayment. 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 $300 
copayment for all Ambulatory Surgical Center (ASC) services besides surgical procedures performed during a 
colorectal screening. 
 
 
 
 
 You have been asked to pay a $300 copayment for spinal injection. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers/Medicare-
covered ambulatory surgical center 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 outpatient surgery spinal injection provided on August 18, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve an MPI. The Plan denied your request. The Plan says that the enrollee does 
not meet the criteria to justify an MPI. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an MPI. Our reviewer says that the 
requested MPI is considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has shortness of breath and their preoperative electrocardiogram is abnormal and had changed since 
2021. The planned surgery and anesthesia are not without risk. Our reviewer also found that due to the 
necessity to clear the enrollee's cardiac status for surgery, the requested myocardial imaging test is medically 
appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MPI have been met. Therefore, we decided that the Plan has to pre-approve a 
myocardial perfusion imaging (MPI).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 14, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under open access unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a chiropractic visit and physical therapy 
provided on January 31, 2022. 
 
The enrollee asked the Plan to waive the copayments for a chiropractic visit and physical therapy. The enrollee 
said that they could not afford to pay this. The Plan denied their 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $10 copayment for chiropractic visit. The enrollees contract with the Plan also clearly says that 
enrollees must pay a $10 copayment for physical therapy. 
 The enrollee had been asked to pay $10 for a chiropractic visit. The enrollee had also been asked to pay $10 for 
physical therapy. The total owed is $20 ($10 + $10 = $20). The chiropractic visit falls within the chiropractic 
visit benefit category. The physical therapy falls within the physical therapy benefit category. This means that 
the enrollee had been asked to pay the correct amount based on their contract with the Plan. This cost sharing is 
a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for a chiropractic visit and physical therapy provided on 
January 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital service provided on 
June 27, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital service. You say that you felt you should 
not owe the $20. 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 $20 
copayment for all other Medicare-covered outpatient hospital services.  
 
You have been asked to pay $20 copayment for outpatient hospital service. This item/service falls within the all 
other Medicare-covered outpatient hospital 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 outpatient hospital service provided on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (L0457, L1852, and L2397) 
provided on April 29, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported.  
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no evidence of a face-to-face evaluation taking place. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L0457, L1852, 
and L2397) provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve high-intensity focused ultrasound (HIFU). 
 
You asked the Plan to pre-approve HIFU. You say that HIFU is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for HIFU. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. It appears as though the 
Plan based its decision on a Local Coverage Determination (LCD).  However, the LCD they referenced has 
been retired and is no longer in effect.  There is no specific policy on HIFU in effect currently, so our physician 
reviewer applied general Medicare medical necessity criteria. 
 
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 HIFU. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the records show that the enrollee has localized prostate cancer and is an appropriate candidate 
for HIFU. High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor 
investigational. HIFU was FDA-approved for prostate gland ablation October 9, 2015. HIFU of the prostate 
(CPT 55880) has Medicare coverage as of July 1, 2017. Numerous clinical studies have demonstrated treatment 
efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, 
incontinence and bowel injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HIFU have been met. Therefore, we decided that the Plan has to pre-approve 
high-intensity focused ultrasound (HIFU).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that therapy is not a good option for you due to the 
deteriorating disc in your back. You say that doing therapy hurt your back. You say that your doctor advised 
the only thing to help your back would be the facet joint injections. You also say that you are in a lot of pain 
and not a candidate for surgery. The Plan denied your request. The Plan says that the requested injections are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients with pain that has been 
present for a minimum of 3 months with documented failure to respond to noninvasive conservative care 
management (as tolerated). 
 
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 injections. Our reviewer says that 
the requested facet joint injections are medically necessary. Our physician reviewer found the provided 
documentation indicates that you tried but were not able to tolerate physical therapy. Therefore, the reviewer 
found that the requested injections are 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 the injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections (64493, 64494).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test and supplies 
provided on May 13, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that this is the second time a 
provider hit you up for a service without warning. 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 $100 
copayment for Medicare-covered diagnostic procedures and tests.  
 
You have been asked to pay $100 copayment for outpatient diagnostic test. This item/service falls within the 
Medicare-covered diagnostic procedures and tests 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 outpatient diagnostic test and supplies provided on May 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of a portable x-ray machine, the set up of a 
portable x-ray machine and a shoulder x-ray provided on May 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the transportation of portable x-ray machine, the set up of a portable x-ray 
machine and a shoulder x-ray. You say that the claim should be paid at the Medicare allowable rate for non-
participating providers. The Plan denied your request. The Plan says enrollees must receive care from a 
network provider. 
 
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 the transportation of a portable x-ray machine, the 
set up of a portable x-ray machine and a shoulder x-ray provided on May 4, 2022, by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent (J3590). 
 
You asked the Plan to pre-approve Praluent. You say that the enrollee has not tolerated statins and is still not at 
their goal with Zeta and Atorvastatin. The Plan denied your request. The Plan says Praluent is on the self-
administered drug list and is excluded from coverage under Part B. 
 
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 Praluent (J3590).  
 
Benefits for Praluent 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not 
tried any of the preferred agents. The Plan also says that a rationale has not been provided for use of the non-
preferred product for safety or efficacy. 
 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 Durolane. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Durolane. Our physician reviewer found there is no 
indication that the enrollee has tried and failed the required drugs. Our reviewer also found that there is no 
indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane (J7318).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
 
 
 
 
 You asked the Plan to pay for skilled nursing facility. You say that you are appealing this claim for no payment 
due to no prior authorization. The Plan denied your request. The Plan says if the enrollee needs Medicare-
covered medical care and a network provider is unable to provide this care, you may be able to get care from an 
out-of-network provider. Our plan must confirm there is not a network provider available, and the out-of-
network provider must contract the plan to request an authorization for you to obtain services. If approved, the 
out-of-network provider will be issued an authorization to provide the service(s). 
 
 
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 skilled nursing facility provided on February 22, 
2022, by an out-of-network (OON) provider.