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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for medical 
complexity requiring physician oversight as well as skilled therapy. You also say that the enrollee is eligible for 
long term acute care benefits per the Center for Medicare and Medicaid Services (CMS) definitions. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee has need for complex medical 
treatment in a LTACH. The reviewer found that the enrollee does not require services at the LTACH that are 
not available at the acute care hospital or the skilled nursing facility. Therefore, the reviewer found that the 
requested LTACH services are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cough stimulating device, alternating positive and 
negative airway pressure (E0482). 
 
You asked the Plan to pre-approve a cough stimulating device. You say that the enrollee has a diagnosis of 
bronchiectasis, however, she does get mucous plugs at times which she is unable to adequately cough up to 
clear her lungs. The enrollee is on all the appropriate nebulized medications and uses an acapella device which 
has been ineffective in clearing her lungs. She would benefit with this device to help avoid future mucous plugs 
and hospitalizations. The Plan denied your request. The Plan says the requested device does not meet the 
requirements for approval. 
 
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 cough stimulating device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a diagnosis of bronchiectasis. The records show episodes 
of mucous plugging with lobar atelectasis. Bronchoalveolar lavage has repeatedly shown branching fungal 
hyphae consistent with Aspergillus, and increased eosinophils. This can be seen with allergic 
bronchopulmonary aspergillosis, which may explain the recurrent mucous plugging and atelectasis. The 
enrollee does not have a neuromuscular disease that is impairing diaphragmatic function.  There are no 
pulmonary function test results. 
 
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 cough stimulating device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a cough stimulating device, alternating positive and negative airway pressure 
(E0482).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve 
(intracept procedure) (64628). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the intracept procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says this request does not 
meet the requirements for approval. 
 
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 an intracept procedure. Our reviewer 
says that a thermal destruction of intraosseous basivertebral nerve is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the intracept procedure is experimental. Our reviewer also 
found that more research is needed. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve (intracept procedure) 
(64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services provided 
from August 4, 2021, to August 7, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that the services 
should be 100% covered and you would like the Plan to fix the provider being out-of-network. The Plan denied 
your request. The Plan says the services were covered at an in-network benefit level and 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 20% 
coinsurance for each Medicare-covered hospital stay. The total allowed amount for the dates of services was 
$9,733.13 with a coinsurance of $1,946.63 ($9,733.13 total allowed amount x 20% coinsurance). 
 
You have been asked to pay a $1,946.63 coinsurance for the inpatient hospital services. This item/service falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the inpatient hospital services provided from August 4, 2021, to August 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says admission to IRF was denied as not meeting AIR criteria, not medically necessary, and a 
lower level of care might be appropriate. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve an ESI. You say that the enrollee's has tried conservative measures. You say 
that they are no longer working. You say that it has been recommended repeating corticosteroid injection for 
pain relief. The Plan denied your request. The Plan says the requested injection is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that an epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements are met. 
 
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 ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate the pain score and pain affecting the enrollee's activities of daily living (ADL). The reviewer found 
there is no history of radiculopathy, and no history of participation in conservative therapy, other than oral 
medications. Therefore, the reviewer found that the requested ESI 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 an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical services provided on May 11, 
2022. 
 
You asked the Plan to waive the copayment for medical services. You say that you are appealing the 
copayment for an annual wellness visit because you feel you should not owe it. 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 $10 
copayment for annual wellness visit.  
 
You have been asked to pay $10 copayment for medical services. This item/service falls within the annual 
wellness 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 medical services provided 
on May 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you require more therapy than can be 
provided at an acute care hospital. The Plan denied your request. The Plan says LTACH care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you appear to be more stable and improving, tolerating weaning, and should only 
require short-term additional acute care services that can safely be administered at the current facility until 
more appropriate for a lower level of care. You do not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 12 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 63 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a specialist visit. You say that you are appealing the denied services with 
your current Ophthalmologist because you have been seeing her for two years and she is no longer contracted 
with the Plan. The Plan denied your request. The Plan says the requested provider is no longer contracted with 
the Plan. The Plan says that services can be performed by an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging of orbit, face, and/or neck 
(70540). 
 
You asked the Plan to pre-approve an MRI of orbit, face, and/or neck. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of orbit, face, and/or neck. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee qualifies 
for an MRI of the cervical spine (72141). The referring clinician has ordered an MRI of the soft tissues of the 
neck (70540) which is an inappropriate study for the patient's symptoms. 
 
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 MRI of orbit, face, and/or neck have not been met. Therefore, we decided 
that the Plan does not have to pre-approve magnetic resonance imaging of orbit, face, and/or neck (70540).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa tablets. 
 
You asked the Plan to pre-approve Gemtesa tablets. You say that the enrollee is currently taking this 
medication. The Plan denied your request. The Plan says Gemtesa is a self-administered drug, and does not fall 
under Part B 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 Gemtesa tablets.  
 Benefits for Gemtesa tablets 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 19, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you do not understand why 
you should pay $34.41 when the provider is listed as an in-network provider. 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% 
coinsurance for outpatient hospital services.  
 
 
 
 
 
 
 You have been asked to pay $34.41 for laboratory services. This item/service falls within the 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 laboratory services 
provided on July 19, 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 the admission was initially denied as the enrollee 
was not medically ready. You say that it is anticipated that the enrollee will be by November 14, 2022. You 
also say that this needs to be approved to avoid delays in their care. The Plan denied your request. The Plan 
says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no 
documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the requested IRF 
admission 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided from April 1, 
2022, to May 9, 2022. 
 
You asked the Plan to waive the copayments for physical therapy. You say that this was an essential service 
ordered by and required by your orthopedic surgeon for a successful recovery from surgery. You feel that an 
essential service should be fully covered as part of the entire procedure and are asking the Plan to waive the 
copayments. 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 for 
outpatient rehabilitation services.  
 
 
 
 You have been asked to pay $600 for physical therapy ($40/visit x 15 visits = $600). This item/service falls 
within the outpatient rehabilitation 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 copayments 
for physical therapy provided from April 1, 2022, to May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung 
expansion device. 
 
You asked the Plan to pre-approve a Volara system-high frequency oscillation lung expansion device. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested item is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the Volara systems are only covered for certain 
indications.  
 
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 Volara system-high frequency 
oscillation lung expansion device. Our reviewer says that the documentation does not support that the requested 
device is medically reasonable or necessary. Our physician reviewer found the enrollee has bronchiectasis and 
pulmonary infection with Mycobacterium avium-intracellulare (MAI). The enrollee already has the Vest 
system and nebulized hypertonic saline for airway clearance. The Volara System combines intra-pulmonary 
oscillation, nebulization, and positive end-expiratory pressure for "lung expansion". There is no convincing 
evidence that intrapulmonary oscillation is superior to high-frequency chest wall oscillation, which the enrollee 
is using. The enrollee already has a nebulizer. There is no evidence that "lung expansion" is beneficial in 
pulmonary MAI disease. 
 
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 Volara system-high frequency oscillation lung expansion device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Volara system-high frequency 
oscillation lung expansion device.