Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1845). 
 
You asked the Plan to pre-approve a knee brace. You say that this is medically reasonable and necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the records show that you do not have recent 
injury or surgery or objective evidence of instability. 
 
The Plan follows Medicare rules. Medicare rules say that a knee brace is subject to the criteria listed 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 a knee brace. Our reviewer says that the 
requested knee brace is not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not reveal that the knee brace coded L1845 is medically necessary. The brace is covered if 
the patient has had recent injury to or a surgical procedure on the knees. The requested knee brace can also be 
covered for a patient who is ambulatory and has knee instability documented with an objective description of 
joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). The documentation does not reveal 
objective physical exam evidence of knee instability. There is no evidence of recent injury or surgery to the 
knees. The criteria for coverage of the requested device have not been met. 
 
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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee brace (L1845).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Skilled nursing evaluation provided on October 11, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for Skilled nursing evaluation. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Skilled nursing evaluation provided on October 
11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that platelet rich plasma injections are not a covered 
benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of platelet rich plasma injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prosthetic devices provided on February 8, 
2022. 
 
You asked the Plan to waive the coinsurance for prosthetic devices. You say that you were never explained the 
cost after having several meetings. 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 20% 
coinsurance for in-network prosthetic devices.  
 
 
 You have been asked to pay a total of $1,208.76, which is 20% coinsurance for prosthetic devices on February 
8, 2022. Prosthetic devices fall within the Prosthetic Devices and Related Supplies benefit category.  
 
Code Allowed Amount 20% Coinsurance 
L5700LT $3,453.77 $690.75 
L5620LT $280.58 $56.12 
L5629LT $300.59 $60.12 
L5637LT $281.60 $56.32 
L5910LT $342.58 $68.52 
L5665LT $484.31 $96.86 
L5668LT $106.13 $21.23 
L5670LT $280.16 $56.03 
L8400LT $210.71 $42.14 
L8470LT $75.71 $15.14 
L8420 $227.66 $45.53 
Total  $1,208.76 
 
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 prosthetic devices provided on February 8, 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 you need inpatient physical therapy, occupational 
therapy, and speech to regain your independence and ensure your safety in the home. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Our reviewer also 
found that specifically, you are not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. 
 
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 an intravenous infusion for therapy, prophylaxis, or 
diagnosis, a normal saline solution infusion, a ferric carboxymaltose injection, and laboratory services provided 
on January 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an intravenous infusion for therapy, prophylaxis, or diagnosis, a normal saline 
solution infusion, a ferric carboxymaltose injection, and laboratory services. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 intravenous infusion for therapy, prophylaxis, 
or diagnosis, a normal saline solution infusion, a ferric carboxymaltose injection, and laboratory services 
provided on January 3, 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 $348.99 coinsurance for the udenyca injection received on 
March 23, 2021. 
 
You asked the Plan to waive the $348.99 coinsurance for this injection. You say that you should not have to 
pay this amount as you had already met your out-of-pocket maximum. The Plan denied your request. The Plan 
says you must pay a 20% coinsurance for Part B covered drugs.  
 
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 Part B prescription drugs.  
 
 You have been asked to pay 20% coinsurance for an udenyca injection. This injection falls within the Medicare 
Part B prescription drugs benefit category. Please note, at the time this claim was processed you had not yet 
reached your out-of-pocket maximum. You have been asked to pay a $348.99 coinsurance for the udenyca 
injection. The allowed amount for this service is $3,228.96. 20% of $3,228.96 is $645.79. 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 $348.99 coinsurance for the udenyca injection received on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have waive your $250 copayment for cataract removal surgery performed on 
December 13, 2021. 
 
You asked the Plan waive your $250 copayment for cataract removal surgery. You say that you were unaware 
that cataract removal was considered surgery. The Plan denied your request. The Plan says you must pay a 
$250 copayment per visit for Medicare-covered outpatient surgery. 
 
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 $250 
copayment Medicare-covered outpatient surgery.  
 
 You have been asked to pay $250 copayment for cataract removal surgery. Cataract removal surgery falls 
within the outpatient surgery 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 waive your $250 copayment for cataract 
removal surgery performed on December 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolia provided to the enrollee on December 20, 2021. 
 
You asked the Plan to pay for the drug. You say that this should be paid for. The Plan denied your request. The 
Plan says the drug was provided by a pharmacy and was not a buy and bill; therefore, this is not eligible for 
coverage under the enrollee's medical plan. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for Prolia provided to the enrollee on December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have waive the $50 copayment for an endoscopy performed on 
 
You asked the Plan waive the $50 copayment for an endoscopy performed on September 15, 2021. You say 
that you were not aware you would be responsible for a $50 copayment for this service. The Plan denied your 
request. The Plan says you must pay a $50 copayment for an endoscopy. 
 
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 outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay a $50 copayment for an endoscopy. An endoscopy falls within the outpatient 
diagnostic tests and therapeutic services and 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 waive the $50 
copayment for an endoscopy performed on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transthoracic echocardiography (93306) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient services. You say that the enrollee had been established and 
received routine care with her cardiologist at the facility. The in-network facility is scheduling as far out as 6 
months. The out of network facility can perform this test in a timely fashion. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 transthoracic echocardiography (93306) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on October 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and the service rendered to the enrollee was out of good faith. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there were in-network providers that could of 
provided the service. Also, the service rendered was not urgent or emergent and there was no approved 
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 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 home health visit provided on October 14, 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 anti-reflective coating (code V2750) and progressive lenses 
(code V2200) you received on December 15, 2021. 
 
You asked the Plan to pay for the anti-reflective coating and the progressive lenses. You say that this provider 
was in-network, so these should be covered. The Plan denied your request. The Plan says these items are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that anti-reflective coating is only covered when the 
provider documents medical necessity.  This is done by adding a KW modifier to the claim. Progressive lenses 
are non-covered. Your contract explicitly states that only standard glasses are covered. The Plan paid for the 
frames you received but denied payment for the anti-reflective coating and the progressive lenses.  Medicare 
rules explicitly state that progressive lenses are never covered.  In addition, anti-reflective coating is only 
covered if your provider bills with a modifier indicating this is medically necessary for you. The provider did 
not append this modifier to the claim, so the anti-reflective coating is also not covered. 
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anti-reflective coating and the progressive lenses have not been met. Therefore, we decided that 
the Plan does not have to pay for anti-reflective coating (code V2750) and progressive lenses (code V2200) you 
received on December 15, 2021.
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 clinical information provided 
supports LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have not been 
met. The Plan says that the services needed could be provided in another 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 intracranial hemorrhage, 
hematoma, hydrocephalus, and mass effect following fall at home. The course was complicated by acute 
respiratory failure requiring intubation and later, trach placement. Recent notes describe the enrollee with 
ongoing encephalopathy but tolerating trach collar and tube feeds via PEG. The enrollee appears to be 
improving but is still somewhat unstable and should only require short-term acute care services that can safely 
be administered at the current facility until appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to an LTACH is not medically necessary as it would not be clinically appropriate or advantageous at this time. Completion of care 
at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that 
the enrollee could receive care in another setting. 
 
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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and COVID-19 pneumonia. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the enrollee has 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 the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hydrogen breath test for diagnosing small bowel 
bacterial overgrowth. 
 
You asked the Plan to pre-approve the diagnostic testing. You say that the requested test is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lactulose breath hydrogen for diagnosing small bowel 
bacterial overgrowth and measuring small bowel transit time is not covered by Medicare. 
 
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 diagnostic testing. Our reviewer 
says that the requested procedure is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the enrollee meets the criteria for coverage for the requested hydrogen 
breath test. 
 
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 diagnostic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a hydrogen breath test for diagnosing small bowel bacterial overgrowth.