Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall, then was transferred to an inpatient rehabilitation facility and now 
has been transferred to skilled nursing. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81479) provided on June 5, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct place of service. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for Guardant360 testing (81479) provided on June 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy and the office visit provided on October 26, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy and the office visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for psychotherapy and the office visit provided on October 26, 2021, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply, accessory and/or service component 
(V2797) and vision item or service, miscellaneous (V2799) provided October 21, 2021. 
 
You asked the Plan to pay for the additional eyeglasses and edge polish. You say that you would like this 
covered. The Plan denied your request. The Plan says you have exceeded the limit for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one pair of eyeglasses after each 
cataract surgery that includes insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that one pair of 
eyeglasses were covered after your cataract surgery. Based on this information, we decided that the Plan's 
frequency limit for coverage post-cataract eyeglasses has been exceeded. The additional eyeglasses are not 
covered. Additionally, upgrades to lenses are not covered.  Therefore, we decided that the Plan does not have to 
pay for the vision supply, accessory and/or service component (V2797) and vision item or service, 
miscellaneous (V2799) provided October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lesion excision (11406) and wound repair (12032) 
provided on September 24, 2021. 
 
You asked the Plan to pay for the lesion excision (11406) and wound repair (12032). You say that the records 
show the CPT codes billed are not bundled and are reimbursable. You say that the claim should be processed 
for payment. The Plan denied your request. The Plan says CPT codes 11406 and 12032 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11406 is excision, benign lesion including margins, 
except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm. The CPT Code 
Manual definition of code 12032 is repair, intermediate, wounds of scalp, axillae, trunk and/or extremities 
(excluding hands and feet); 2.6 cm to 7.5 cm.  We asked our coder 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 lesion excision (11406) and wound repair (12032). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the procedure report does not document would measurements including margins to verify 
accurate code to report. CPT code 11406 is reported by excised diameter, which is not documented in the 
procedure report. The procedure report also does not document wound measurements including margins to 
verify accurate code to report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lesion excision (11406) and wound repair (12032) have not been met. 
Therefore, we decided that the Plan does not have to pay for the lesion excision (11406) and wound repair 
(12032) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that there is no copayment if 
a procedure is done. 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 $40 
copayment for each visit with a specialist.  
 
You have been asked to pay a $40 copayment for the specialist office visit. The file shows there was no charge 
for the procedure. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's 
Office Visits benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit 
provided on November 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional Physical Therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 additional PT visits. You say that the requested services are medically 
necessary. 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 Medicare pays for medically necessary outpatient 
therapy. 
 
  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 8 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. The enrollee and spouse have been instructed in a home exercise program. The requested services are 
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to 
prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional Physical Therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for F. Rice, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayments for a chest x-ray and a computed tomography (CT) scan 
of the chest provided from December 23, 2021, to December 24, 2021. 
 
You asked the Plan to waive the copayments for an x-ray and a CT scan. You say that you should only have a 
$90 copayment for an ER visit. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $90 copayment for an emergency room visit. The contract 
also clearly says emergency care includes services that are needed to evaluate or stabilize an emergency 
medical condition. 
 
The Plan says you must pay a total of $221.50 for an x-ray and a CT scan. Based on the Plan contract, 
however, you cannot be asked to pay separate, additional amounts for an x-ray and a CT scan as emergency 
care. According to the Plans contract, emergency care included services that are needed to evaluate or stabilize 
an emergency medical condition. Therefore, we decided that the Plan has to waive the copayments for a chest 
x-ray and a computed tomography (CT) scan of the chest provided from December 23, 2021, to December 24, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix, Atropine sulfate, Leucovorin calcium, 
Dexamethasone sodium phosphate, Fluorouracil, and Irinotecan. 
 
You asked the Plan to pre-approve Vectibix, Atropine sulfate, Leucovorin calcium, Dexamethasone sodium 
phosphate, Fluorouracil, and Irinotecan. You say that the medications 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 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 Vectibix, Atropine sulfate, Leucovorin 
calcium, Dexamethasone sodium phosphate, Fluorouracil, and Irinotecan. Our reviewer says that the 
medications are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Vectibix, Atropine sulfate, Leucovorin calcium, Dexamethasone 
sodium phosphate, Fluorouracil, and Irinotecan is medically reasonable and necessary or safe and effective 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 Vectibix, Atropine sulfate, Leucovorin calcium, Dexamethasone sodium 
phosphate, Fluorouracil, and Irinotecan have not been met.  Therefore, we decided that the Plan does not have to pre-approve Vectibix, Atropine sulfate, Leucovorin 
calcium, Dexamethasone sodium phosphate, Fluorouracil, and Irinotecan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. The laboratory services are 
not billed correctly. The rules say that if one laboratory procedure evaluates multiple genes using a next 
generation sequencing procedure, the laboratory shall report only one unit of service of one genomic 
sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. If no code accurately describes the procedure performed, the laboratory 
may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on March 15, 2021, by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Intraosseous Nerve Ablation system. 
 
You asked the Plan to pre-approve an Intracept Intraosseous Nerve Ablation system. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept Intraosseous Nerve 
Ablation system. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More 
research is needed to show safety and efficacy. 
 
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 Intraosseous Nerve Ablation system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Intracept Intraosseous Nerve Ablation system.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Eylea. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found based on the medical records provided 
the enrollee has not tried and failed the required drug. There is no indication that the plan's required drug 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the available suppliers do 
not carry this item or any other supplier in the area of the long trip you are taking. The Plan denied your 
request. The Plan says the provider is out-of-network. 
 
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 
the portable oxygen concentrator to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2313, E2377). You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 the accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested accessories are not medically necessary as you do not have use of his hands and 
can operate and control the power options using the switches that are included in the basic wheelchair.  
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2300, E2313, E2377).
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 this patient has mobility and strength issues and 
requires SNF care. The Plan denied your request. The Plan says the patient does not meet SNF coverage 
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 the patient does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal 
evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The patient's 
functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of 
a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a 
daily basis in a SNF.  As a practical matter  this patient does not require the necessary services on 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.