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

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart (75571). 
 
You asked the Plan to pre-approve the CT of the heart. You say that you would like reconsideration because 
this service is medically necessary. The Plan denied your request. The Plan says there are no symptoms or 
objective findings of coronary ischemia. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT of the heart. Our reviewer says 
that CT imaging of the heart without contrast material with quantitative evaluation of coronary calcium is 
considered experimental/investigational for the evaluation and management of this enrollee's medical 
condition. Our physician reviewer found there is insufficient support in the peer-reviewed literature 
demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of coronary calcium 
in guiding optimal management of this 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 the CT of the heart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve computed tomography (CT) of the heart (75571).
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 enrollee is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. While the enrollee may benefit from physical therapy, and occupational therapy, the 
enrollee's rehab can be safely provided at a lower intensity and alternate setting such as in a skilled nursing 
facility or in-home with 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 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 pay for the opioid treatment provided on July 20, 2021. 
 
You asked the Plan to pay for the services provided. You say that you have to appeal to receive your money. 
The Plan denied your request. The Plan says the provider is not an approved Medicare provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you receive your care from a provider who is eligible to provide services under Original 
Medicare. 
 
The requested provider in this case is not a network provider with the Plan, nor is eligible to provide services 
under Original Medicare. 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 the 
opioid treatment provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve ablation provided on November 11, 
2021. 
 
You asked the Plan to pay for the provided services. You say that the services are not experimental. The Plan 
denied your request. The Plan says the nerve blocks are considered investigational for the treatment of chronic 
knee pain. 
 
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 pay for the provided services. Our physician 
reviewer found that the enrollee has osteoarthritis of the right knee. She has tried over-the-counter medications 
and Euflexxa injections. She underwent 2 sets of genicular nerve blocks and achieved greater than 80% pain 
relief each time. She then underwent radiofrequency ablation of the right genicular nerves. This is considered 
an experimental/investigational procedure. Its role in the treatment of knee osteoarthritis is still being 
evaluated. Therefore, the procedure was 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 provided services have not been met. Therefore, we decided that the Plan 
does not have to pay for the genicular nerve ablation provided on November 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 19, 2021 to March 19, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because the 
RAP rule was not being enforced on the billed dates of service. The Plan denied your request. The Plan says 
the provider did not follow Medicare guidelines. 
 The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
indicates that the RAP was not submitted within 5 days of the start of care. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from February 19, 2021 to March 19, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were recently hospitalized with 
an acute exacerbation of COPD, and ABGs showed CO2 retention. You may benefit from bipap during sleep, 
which can provide the AVAPS mode that has been ordered. But Medicare does not cover a ventilator when 
used as bipap. Bipap has not been tried and failed at home. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the IRF stay provided from November 30, 
2021, to December 11, 2021. 
 
You asked the Plan to waive the copayment for the IRF stay. You say that you can't understand how you can be 
charged for two hospital stays when you were only moved from one room to another. The Plan denied your 
request. The Plan says the copayment applied 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 $325 
copayment per admission for each medically necessary inpatient stay.  
 
You have been asked to pay a $325 copayment for the IRF stay. The IRF stay 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 copayment for the IRF stay provided from 
November 30, 2021, to December 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on November 1, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable and does not need PM&R physician close supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. While you may benefit from physical therapy, and occupational therapy, your rehab can be 
safely provided at a lower intensity and alternate setting such as in a skilled nursing facility or in-home with 
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 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 pay for the anesthesia for a person of an extreme age (99100) 
provided on November 29, 2021. 
 
You asked the Plan to pay for the anesthesia service. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator of B. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia for a person of an extreme age (99100) provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravitreal injection provided on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for an intravitreal injection. You say that the claim was billed as an 
operating room service which you want removed since you do not want the provider to bill with that code. You 
also say you do not agree with paying a copayment of $250. 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 $250 
copayment for outpatient surgery at an outpatient hospital.  
 
 The record shows an intravitreal injection is considered a surgical procedure. The record also shows this claim 
was approved, and you have a cost sharing amount. You have been asked to pay a $250 copayment for an 
intravitreal injection. An intravitreal injection 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 an intravitreal injection provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81291, 81479) rendered by the out-
of-network (OON) provider on June 7, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the laboratory services (81291, 81479) rendered by the out-of-network (OON) 
provider on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP machine provided on December 
14, 2021. 
 
You asked the Plan to waive the coinsurance for CPAP machine. You say that your CPAP machine was 
recalled, therefore you should not be responsible for the 20% cost of the new machine and initial setup. The 
Plan denied your request. The Plan says the coinsurance is correct. 
 
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 Medicare-covered DME items.  
  You have been asked to pay $77.40, which is 20% of the allowed amount for the CPAP machine. The allowed 
amount is $387.01 (20% x $387.01 = $77.40). The CPAP machine falls within the Durable Medical 
Equipment (DME) and Related Supplies 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 CPAP machine provided on December 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
December 27, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you stayed in the hospital for two 
days and you should not have an ER copayment. 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 $50 
copayment for each emergency room visit.  
 
The file shows that you went to the ER and stayed under observation status only. Therefore, you have been 
asked to pay a $50 copayment for the ER visit. The ER visit falls within the Emergency 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 copayment for an emergency room (ER) visit provided on December 27, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Baclofen. 
 
You asked the Plan to pre-approve Baclofen. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Baclofen.  
 
Benefits for Baclofen 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 waive the coinsurance for an injection of tildrakizumab (a Medicare 
Part B prescription drug) provided on December 21, 2021. 
 
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you were not told about the cost 
upfront and its just not affordable for you. The Plan denied your request. The Plan says the coinsurance 
amount you are being charged is correct. 
 
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% in-
network coinsurance for Medicare Part B prescription drugs. The allowed amount for the drug was $13,418.27, 
resulting in a total coinsurance amount of $2,681.40. 
 
 You have been asked to pay 20% in-network coinsurance for a Part B drug. Part B drugs falls within the 
Medicare Part B prescription drugs 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 
an injection of tildrakizumab (a Medicare Part B prescription drug) provided on December 21, 2021.
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 daily 
skilled services are not necessary. Our physician reviewer found you received oral and inhaled medications and 
insulin. You have stable vital signs and use oxygen via nasal cannula. You were at a contact guard assist level 
for functional mobility including gait to 160 feet. You do not require skilled nursing or therapy services on a 
daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires the services on an inpatient basis, only in a skilled nursing facility setting. Records do not 
document that services in the home with home health care or in a long-term care facility on a part time basis are 
not appropriate in this case. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Skilled Nursing Facility (SNF) admission.