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

 
We decided that the Plan has to pay for outpatient services provided on May 10, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were billed correctly. The Plan 
denied your request. The Plan says that the claim needs to be resubmitted with modifier 25. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare coding rule to substantiate 
their denial. Therefore, we decided that the Plan has to pay for outpatient services provided on May 10, 2022.  
 
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 Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ESAs may be administered by intravenous or 
subcutaneous routes. 
 
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 Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records revealed that the 
enrollee's transferrin level was not at least 20% or ferritin at least 100 recently to meet the LCD coverage 
criteria. Hemoglobin (Hgb) was 10.5, transferrin percentage was 12%, and ferritin was not provided. Therefore, 
the enrollee does not meet the LCD coverage criteria for Retacrit use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on February 23, 
2022. 
 
You asked the Plan to pay for the CXbladder detect test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the CXbladder detect test have not been met. Therefore, we 
decided that the Plan does not have to pay for the CXbladder detect test (0012M) provided on February 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve a SI joint injection. 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 a SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no physical exam findings to support this diagnosis. There is no imaging to 
support this diagnosis. There is no symptomatology that points to the SI joint. The request is not medically 
reasonable and 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 a SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization and associated 
procedures (37223, 37253, 37252, 75710, 76937, 75774, 75625, 75630, 99152, 99153) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve endovascular revascularization and associated procedures to be provided by 
an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there 
are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
endovascular revascularization and associated procedures (37223, 37253, 37252, 75710, 76937, 75774, 75625, 
75630, 99152, 99153) 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 a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD) with repeated 
hospitalizations. There is no documentation of chronic carbon dioxide (CO2) retention with arterial blood gas 
(ABG) done while stable. If the enrollee does have chronic CO2 retention, may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS). This has not been tried and failed as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on April 3, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that Original Medicare would be responsible for payment of all 
Medicare covered services related or unrelated to the members terminal condition. The Medicare hospice 
benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date 
of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician 
services and all care unrelated to the terminal illness until the first day of the month following the month in 
which hospice was revoked or discharged. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided proof of hospice enrollment to 
substantiate their denial. Therefore, we decided that the Plan has to pay for physician's services provided on 
April 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zynex E-Wave and monthly supplies provided to the 
enrollee on August 9, 2022. 
 
You asked the Plan to pay for the items. You say that this should be paid for. The Plan denied your request. 
The Plan says the information does not sufficiently support the billed supply code. 
 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the items have been met. Although the 
case has a prescription and proof of delivery, the only medical records are for July 22, 2020, two years before 
the date of service in this case. There were timely medical records provided in this case. The medical records 
provided do not mention the device at issue in this case. Therefore, we decided that the Plan does not have to 
pay for the Zynex E-Wave and monthly supplies provided to the enrollee on August 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex interlaminar stabilization device. 
 
You asked the Plan to pre-approve a Coflex interlaminar stabilization device. 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 a Coflex interlaminar stabilization 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the coflex device is experimental. 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 a Coflex interlaminar stabilization device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Coflex interlaminar stabilization device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve electronic brachytheraphy. 
 
You asked the Plan to pre-approve electronic brachytheraphy. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 electronic brachytheraphy. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the services are necessary to avoid extensive, potentially disfiguring surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytheraphy have been met. Therefore, we decided that the Plan 
has to pre-approve electronic brachytheraphy.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in 2021, the enrollee underwent a cardiac workup, including radionuclide stress test 
and cardiac catheterization, both unremarkable. Repeat non-invasive workup has not been performed. 
Guidelines would not support the necessity of repeating these invasive procedures at this time. In summary, 
there is insufficient documentation to support the medical necessity of cardiac catheterization in this enrollee's 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs increased 
monitoring, continued pulmonary management and daily physician involvement for complex medical 
management with an interdisciplinary treatment team approach. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary, and the enrollee can safely receive the care they need in current 
hospital setting. 
 
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 the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The medical records do not indicate that the enrollee requires services that 
she is not currently receiving but that would be available at the LTACH facility. 
 
   
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 LTACH services.
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 LTACH is medically necessary, and 
the enrollee qualifies for the services. The Plan denied your request. The Plan says the LTACH is not medically 
necessary, and the enrollee's needs are being met at the current acute care setting. 
 
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 enrollee was admitted to the acute care hospital with a urinary tract infection 
(UTI), encephalopathy, and hematuria requiring fluids and antibiotics and complicated by acute kidney injury 
and acute respiratory failure due to chronic obstructive pulmonary disease (COPD) exacerbation and 
pneumonia. The medical record shows the enrollee as responding to treatment with resolved encephalopathy, 
tolerating hemodialysis, tolerating low dose oxygen support, but requiring ongoing physical therapy and pain 
management. The enrollee appears to be improving with treatment and should only require short-term 
additional acute care services that can safely be administered at the current facility until more stable and appropriate for a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ReActiv8 device. 
 
You asked the Plan to pre-approve a ReActiv8 device. 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 a ReActiv8 device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental procedure. Therefore, the request is deemed not 
medically reasonable and 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 a ReActiv8 device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ReActiv8 device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a specialist office visit and shaving of 
epidermal or dermal lesion provided on August 17, 2022. We also decided that the Plan does not have to waive 
the cost sharing for a specialist office visit and destruction of precancer skin growth provided on  
August 31,2022. 
 
You asked the Plan to waive the cost sharing for a specialist office visit, shaving of epidermal or dermal lesion, 
and destruction of precancer skin growth. You say that your out-of-pocket maximum had been met. 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 your combined out-of-
pocket maximum is $1,300.  
 You have been asked to pay $14.62 for a specialist office visit (99213), $40.13 for shaving of epidermal or 
dermal lesion (11301), $16.78 for shaving of epidermal or dermal lesion (11300), and $9.58 for shaving of 
epidermal or dermal lesion (11310) provided on August 17, 2022. These items/services fall within the specialist 
visit benefit category. You have also been asked to pay $14.62 for a specialist visit (99213), $10.98 for 
destruction of precancer skin growth (17000), and $7.54 for destruction of a precancer skin growth (17003) 
provided on August 31, 2022. These items/services fall within the specialist visit benefit category. The amount 
you owe is $114.25. 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. At 
the time these claims were processed, your out-of-pocket maximum had not been met. Therefore, we decided 
that the Plan does not have to waive the cost sharing for a specialist office visit and shaving of epidermal or 
dermal lesion provided on August 17, 2022, and a specialist office visit and destruction of a precancer skin 
growth provided on August 31,2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs are too complex for 
a lower level of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The medical records do not indicate that the enrollee requires services that 
she is not currently receiving but that would be available at the LTACH facility. 
 
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 LTACH services.