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

 
We decided that the Plan does not have to pay for the outpatient visit (99214) provided on March 28, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. You say that you were told by a Plan representative that 
authorization was not required. The Plan denied your request. The Plan says the service was provided out-of-
network and was not approved in advance. 
  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 outpatient visit (99214) provided on March 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation of the right sacroiliac (SI) joint 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 Medicare states that radiofrequency ablation used for sacroiliac 
joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. 
 
We looked at 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 
ablation of the right sacroiliac (SI) joint for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
can, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolaris testing. 
 
You asked the Plan to pre-approve Prolaris testing. The Plan denied your request. The Plan says that the 
records do not show that a tissue sample was collected before you received treatment. 
 
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 has failed to obtain medical records from a contracted 
provider. A contracted provider is considered to be an agent of the Plan. This means that it is the Plan's 
responsibility to obtain the medical records required to support its denial. Therefore, we decided that the Plan 
has to pre-approve Prolaris testing.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all endoskeletal lower extremity prosthesis, axial 
rotation unit, with or without adjustability (L5984), an all-lower extremity prosthesis, multi-axial rotation unit 
(L5986), an addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988) and an all-lower 
extremity prosthesis, flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve a socket system. You say that the requested socket system is medically 
necessary. The Plan denied your request. The Plan says the requested socket system 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 a socket system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Rush Rampage foot represented by code L5981 and L5986 exceeds the enrollee's medical 
needs and is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k). The treating medical physician documentation does not support that the enrollee is a K3 ambulator. 
The enrollee was using a cane and then regressed to a walker. The provider recommends physical therapy to 
see if he can attain his goal of ambulating without an assistive device. Furthermore, the axial rotation L5984 
exceeds the enrollee's medical needs as the L5984 is not needed for the Rush Rampage foot. The physician 
documentation does not support that he performs high impact activity and requires the L5988 for his functional 
level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a socket system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an all endoskeletal lower extremity prosthesis, axial rotation unit, with or without 
adjustability (L5984), an all-lower extremity prosthesis, multi-axial rotation unit (L5986), an addition to lower 
limb prosthesis, vertical shock reducing pylon feature (L5988) and an all-lower extremity prosthesis, flex-walk 
system or equal (L5981).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fesoterodine Fumarate ER. 
 
You asked the Plan to pre-approve Fesoterodine Fumarate ER. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
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 Fesoterodine Fumarate ER.  
 
Benefits for Fesoterodine Fumarate ER 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 the incontinence supplies rendered on April 14, 2022. 
 
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 services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable. The rules say that the only chiropractic service Medicare 
covers is manual manipulation of the spine to correct a subluxation 
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Furthermore, the file shows that the services were rendered by a chiropractor and these services are 
not covered when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the 
incontinence supplies rendered on April 14, 2022.
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 these services are medically necessary The Plan 
denied your request. The Plan says that you are unlikely to be able to participate in an intensive therapy 
program of three hours of therapy a day at least 5 days a week. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for diverticulitis and COVID-19 
infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device, powered upper extremity 
range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, 
sensors, all components and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the requested MyoPro orthotic 
device is medically necessary. The Plan denied your request. The Plan says the requested MyoPro orthotic 
device 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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature in the peer reviewed publications to assess safety, 
efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for upper 
extremity paralysis/paresis from conditions such as a peripheral nerve injury, brachial plexus injury, or other 
neuromuscular/neurological disease or injury. The requested device is not the standard of care for the enrollee's 
condition. Therefore, per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), the requested 
orthosis is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body 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 a MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device, powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for dialysis services provided from March 8, 2021, to 
May 31, 2021. 
 
You asked the Plan to reduce the cost for dialysis services. You say that you are appealing the coinsurance 
assessed for outpatient dialysis services. The Plan denied your request. The Plan says the coinsurance applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that you must pay a 20% coinsurance, after your $3,900 out-of-pocket 
maximum, for each in and out-of-network Medicare-covered benefits.  
 
 
 
  You have only been asked to pay a total of $2,067.17, which is less than the standard 20% coinsurance because 
you met your $3,900 out-of-pocket maximum. 
 
Dates of Service Service Allowed Amount Coinsurance Enrollee Responsibility 
March 1, 2021- 
March 31, 2021 
Dialysis $3,080 20% $611.17 
April 2, 2021- 
April 30, 2021 
Dialysis $3,640 20% $728 
May 3, 2021-  
May 31, 2021 
Dialysis $3,640 20% $728 
TOTAL    $2,067.17 
 
Dialysis falls within the Services to Treat Kidney Disease 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 cost for dialysis services provided from March 8, 2021, to May 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the magnetic resonance imaging (MRI), of 
the upper extremity joint; without contrast material(s) (73221) provided on March 3, 2022. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 up to $75 per day for Medicare-covered diagnostic radiology services. 
 
 You have been asked to pay $56.08 (Plan allowed amount of $280.42 x 20% coinsurance) for the Medicare-
covered diagnostic radiology service provided. 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 the 
magnetic resonance imaging (MRI), of the upper extremity joint; without contrast material(s) (73221) provided 
on March 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically reasonable and necessary in this case. Our physician reviewer found that based on 
the medical records provided and the Medicare-approved major drug compendia, there is no documentation 
that Feraheme at issue in this case meets Medicare criteria for medically reasonable and necessary. Iron 
deficiency without current anemia is not a medically accepted indication 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.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar spine surgery. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the acupuncture treatments (97810) 
provided from January 12, 2022, through January 25, 2022. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office.  
 
You have been asked to pay $75 ($25 copayment x 3) for the acupuncture treatments provided on January 12, 
2022, January 13, 2022, and January 25, 2022.  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 copayments for the acupuncture treatments (97810) provided 
from January 12, 2022, through January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you do not have documented skilled 
nursing or skilled therapy needs. You are not shown to have an acute decline in function. Daily skilled services 
are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 
Your care needs can, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.