Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the requested CT scan is a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested CT scan is an excluded screening procedure in this case. 
 
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 a CT scan of the heart. Our reviewer 
says that the requested CT scan is not medically reasonable and necessary in this case. Our physician reviewer 
found that you are asymptomatic from a cardiovascular standpoint. Clinical studies have not shown that the 
requested calcium scoring adds value in clinical management of asymptomatic patients in whom risk factors 
are targeted. 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 
patients. As such, CT imaging of the heart without contrast material with quantitative evaluation of coronary 
calcium is considered experimental/investigational for the evaluation and management of your medical 
condition. 
 
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 CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the heart with quantitative evaluation of 
coronary calcium (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on January 25, 2022, to February 
22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you have been seeing this provider for ten years 
who has been treating your multiple sclerosis. You say you want to continue receiving cutting edge treatments 
from this provider. 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
office visits. We found no exception that would require the Plan to pay for the office visits. Therefore, we 
decided that the Plan does not have to pay for the office visits provided on January 25, 2022, to February 22, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on July 8, 2021. 
 
You asked the Plan to pay for vision services. You say that you were unaware prior authorization was needed. 
You also state staffing was short due to COVID-19. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 vision services provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80061, 80053, 82607, 82306) provided 
on February 17, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 laboratory services (80061, 80053, 82607, 82306) 
provided on February 17, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the application of a cast (29075) provided 
on September 2, 2021. 
 
You asked the Plan to waive the copayment for the application of a cast. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on 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 $275 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $275 copayment for the application of a cast. the application of a cast 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 
the application of a cast (29075) provided on September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on February 9, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that modifier -78 is used for return trips to the operating 
room during the post-operative period. 
 
We looked at the file and Medicare rules. The file shows that procedure code 11042 was incorrectly billed with 
the -78 modifier, as the services did not require a return trip to the operating room. Therefore, we decided that 
the Plan does not have to pay for the surgical services rendered on February 9, 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 based on the enrollee's current condition and 
functional deficits, as well as her multiple comorbidities, her attending physicians have determined that she 
meets full IRF criteria. You also say that this is based on the guidelines of both the Centers of Medicare and 
Medicaid Services (CMS) and the Milliman Clinical Guidelines (MCG). The Plan denied your request. The 
Plan says based on Medicare guidelines and the information they have about your condition; you do not meet 
the requirements. 
 
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 the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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 a rest home visit provided on July 21, 2021. 
 
You asked the Plan to pay for a rest home visit. You say that the doctor is a hospitalist physician and depends 
upon the hospital staff to verify eligibility and to obtain proper authorization from the enrollee's insurance 
company. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 a rest home visit provided on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on February 17, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the referring doctor was in-network, and the 
claim should be paid. You say you will be forced to recoup money from the enrollee. 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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on February 17, 2021, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick urine collection. 
 
You asked the Plan to pre-approve Purewick urine collection. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are 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 Purewick urine collection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have recurrent urinary tract infections that cause hospitalization. The Purewick 
urine collection device is not medically reasonable and necessary in this case. There are no peer-reviewed 
articles published in the medical literature specific to the PureWick system, or external urinary collection 
system using a continuous low-pressure pump. Thus, there is no evidence to show the PureWick system to be 
an effective alternative in preventing urinary tract infections that lead to hospitalization. Therefore, you do not 
meet criteria for the requested items. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Purewick urine collection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Purewick urine collection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 an office visit provided on February 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for homecare services (S9122) provided March 8, 2022 to 
March 11, 2022. 
 
You asked the Plan to pay for the homecare services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is liable for payment for this service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for homecare services (S9122) provided March 8, 2022 to March 
11, 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 skilled nursing facility (SNF) care. You say that the admission to a Skilled 
Nursing Facility is medically necessary. The Plan denied your request. The Plan says the requested service is 
not medically necessary. 
 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 skilled nursing facility (SNF) care. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found This beneficiary does 
not meet the 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 skilled nursing facility (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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on January 19, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the service should be covered. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care (99223) provided on January 19, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a viscosupplementation arthrocentesis injection. 
 You asked the Plan to pre-approve viscosupplementation. You say that the enrollee is in a lot of pain and needs 
this drug administered. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the record does not show that the enrollee has failed conservative treatment. 
 
The Plan follows Medicare rules. Medicare rules state that viscosupplementation therapy is only covered is 
certain criteria 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 viscosupplementation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for viscosupplementation therapy. Our physician 
reviewer found the documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive conservative care measures. There were no follow-up exams provided for review to indicate 
improvement with the previous series of injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a viscosupplementation arthrocentesis injection.
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 enrollee needs rehabilitation. The Plan denied 
your request. The Plan says based on Medicare guidelines the enrollee does not meet the requirements for 
approval. 
 
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 at home and was recently hospitalized for failure to thrive and 
dehydration. The enrollee is medically stable. Comorbid conditions are all stable. There are no complex 
nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 
 
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 physician certification for Medicare-covered home health 
services under a home health plan of care provided on December 9, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the physician certification for Medicare-covered home health services under a 
home health plan of care. You say that the provider relies on facility staff to verify eligibility and to obtain 
authorization form the enrollee's insurance company. 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 
physician certification for Medicare-covered home health services under a home health plan of care. We found 
no exception that would require the Plan to pay for the physician certification for Medicare-covered home 
health services under a home health plan of care. 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 physician 
certification for Medicare-covered home health services under a home health plan of care provided on 
December 9, 2021, by an out-of-network (OON) provider.