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 you are submitting records requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do 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 was admitted to an acute hospital on September 9, 2022, after a fall 
sustaining a right hip fracture and underwent an open reduction and internal fixation. The enrollee was noted to 
have an acute kidney injury, urinary retention and had a foley placed. The enrollee is medically stable. While 
the enrollee may benefit from continued physical and occupational therapy the enrollee's rehabilitation needs 
can be safely provided in a lower intensity and alternate setting such as in a skilled nursing 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 20, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that you disagree with the denial of payment and feel 
that the code should be covered. The Plan denied your request. The Plan says an eye refraction is not covered 
by Medicare or the Plan. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover an eye refraction under any circumstance. 
 
We looked at the file and the Plan's rules. The EOC confirms that an eye refraction is not a covered benefit. 
Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on April 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cranial stereotactic radiosurgery. 
 
You asked the Plan to pre-approve cranial stereotactic radiosurgery. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services 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 cranial stereotactic radiosurgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have a diagnosis of essential tremor. On June 23, 2022, it is 
documented that you had a task specific tremor much more substantial with typical spiral of essential tremor. 
Gamma knife thalamotomy and focused ultrasound thalamotomy were discussed with the neurological surgeon. 
The surgeon documents that DBS (Deep brain stimulation) surgery is a better option for you. The 
documentation in the case file includes multiple surgical options and is therefore, insufficient to support that 
stereotactic radiosurgery is 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 cranial stereotactic radiosurgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve cranial stereotactic radiosurgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radio frequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve the radio frequency ablation (RFA). You say that the enrollee has had this 
done before. You say that it has helped in the past. You also say that now it is being denied. The Plan denied 
your request. The Plan says the requested service 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 radio frequency ablation (RFA). 
Our reviewer says that the requested RFA is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the role of genicular nerves RFA is still being evaluated and they are considered 
experimental/investigational at this time.  Therefore, the request for RFA is not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radio frequency ablation (RFA) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radio frequency ablation (RFA) (64624).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 5, 2022, to January 28, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the claim submitted is missing required information. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a valid NOA 
document is required in order to process the final claim. Review of the file shows that a valid NOA was not 
submitted. Therefore, we decided that the Plan does not have to pay for the home health services provided to 
the enrollee from January 5, 2022, to January 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You submitted your bill for review. The Plan 
denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for each Medicare-covered emergency room visit.  
 
 
  You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided on January 
7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on April 08, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for Medicare-covered services provided in an ambulatory surgical center. If you are having surgery 
in a hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. 
Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay 
the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be 
considered an outpatient. 
 
 
 
 You have been asked to pay a $65 copayment for colonoscopy. Colonoscopy falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for colonoscopy on April 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood glucose test or reagent strips for a home blood 
glucose monitor and supplies (A4235, A4253, A4256, A4259) provided on January 7, 2022, to March 27, 
2022. 
 
 
 
 
 You asked the Plan to pay for a home blood glucose monitor and supplies. You say that you disagree with the 
denial of payment. You are requesting reconsideration and have submitted records for review. The Plan denied 
your request. The Plan says the submitted medical records include a physician's order; however, the physician's 
order does not include a physician signature or attestation to authenticate the medical records, electronic or 
otherwise. It is noted that multiple attempts were made to contact the provider for additional information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician signature or attestation to authenticate the medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a blood glucose test or reagent strips for a home blood glucose monitor and supplies (A4235, 
A4253, A4256, A4259) provided on January 7, 2022, to March 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Horizant tablet. 
 
You asked the Plan to pre-approve Horizant. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Horizant tablet.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient eye surgery provided on 
January 18, 2022. 
 
You asked the Plan to waive the copayment for an outpatient eye surgery. You say that you called to determine 
coverage prior to surgery and were not informed of a $275 copayment. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for each Medicare-covered outpatient surgery or procedure at an ambulatory surgical center.  
 
 
  You have been asked to pay a $275 copayment for an outpatient eye surgery. An outpatient eye surgery falls 
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical, benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient eye surgery 
provided on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair (group 3 power wheelchair) 
with two (2) or more power seat options (CPT code K0861) and the other requested items. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the notes do not show that the enrollee needs both of the power options, and the 
upgraded controller, harness and electronics cannot be covered as there is not a medical need to control more 
than two power options through the joystick. The Plan states the controller display and toggle switches are 
bundled and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 DME. Our physician reviewer 
found there is no documentation that the group 3 power wheelchair with multiple power options (power tilt, 
recline and power elevating leg rests) at issue in this case meet Medicare criteria for medically reasonable and 
necessary per LCD L33792 - Wheelchair Options/Accessories. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a special power wheelchair (group 3 power wheelchair) with two (2) or more power seat options 
(CPT code K0861) and the other requested items.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a negative pressure wound therapy 
(NPWT) pump. 
 
You asked the Plan to pre-approve the continued use of a NPWT pump. You say that the enrollee has had slow 
but significant improvement over the last 6 months in healing a trochanteric ulcer. The Plan denied your 
request. The Plan says the documentation shows that the enrollee has completed the 4-month statutory 
maximum per Medicare rules. The Plan says that the documentation provided does not support an individual 
expectation for continuing past the statutory maximum for medical necessity. 
 
The Plan follows Medicare rules. Medicare rules say that NPWT pumps and supplies will be denied as not 
reasonable and necessary when 4 months have elapsed using the NPWT pump in the treatment of the most 
recent wound.  
 
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 continued use of a NPWT pump. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
has a chronic trochanter ulcer improving with NPWT. The records show that he has been using this device and 
has had coverage for 4 months. A request was made for continuation of NPWT for a fifth month. However, the 
enrollee has already completed 4 months of use of the NPWT. 
 
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 continued use of a NPWT pump have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued use of a negative pressure wound therapy (NPWT) 
pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
1, 2022 to July 6, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. 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 $225 
copayment per day for days 1-7 of Inpatient hospital care.  
 
 
  You have been asked to pay a $225 copayment per day for 5 days of inpatient hospital care ($225 x 5 = 
$1,125). 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 inpatient hospital care provided from July 1, 
2022 to July 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a procedure to crush a stone in your ureter 
(52356) rendered on May 9, 2022. 
 
You asked the Plan to waive the copayment for a procedure to crush a stone in your ureter. You say that you 
should not have to pay $300 a day for a hospital room. You also say that treatment was an emergency. The Plan 
denied your request. The Plan says the cost-share was applied correctly.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $325 copayment a procedure to crush a stone in your ureter. The service at issue 
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category.  
 
 This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a procedure to crush a stone in your ureter (52356) rendered 
on May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous electrical nerve stimulator (PENS) 
system. 
 
You asked the Plan to pre-approve the PENS system. You say that the enrollee would be an excellent candidate 
for the PNES unit to help with chronic pain and to reduce the use of narcotics. You say that the enrollee is 
likely to obtain significant therapeutic benefit from the neurostimulator treatment, which will aid in the ability 
to participate in normal activities of daily living and increase blood flow to the affected areas. You say that the 
enrollee has tried and failed conservative care and medication therapies. The Plan denied your request. The 
Plan says the requested services not covered by Medicare or under this contract. 
 
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 PENS system. Our reviewer says 
that a PENS system is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient evidence of this device providing sustained 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 the PENS system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a percutaneous electrical nerve stimulator (PENS) system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a serial tonometry exam (92100) provided 
on February 22, 2022. 
 
You asked the Plan to waive the copayment for the serial tonometry exam. 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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $50 copayment for the serial tonometry exam. Serial tonometry exams fall 
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 to waive the copayment for a serial tonometry exam (92100) provided on February 22, 2022.