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

 
We decided that the Plan does not have to waive the copayment for an office visit on June 10, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share. 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 you must pay a $65 
copayment for an office visit.  
 
You have been asked to pay a $65 copayment for an office visit. This item/service falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit on June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rhizotomy procedure. 
 
You asked the Plan to pre-approve the requested services. You say that you cannot walk without being in pain. 
The Plan denied your request. The Plan says medical necessity could not be established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. In this case, there are no records from your treating physician to 
show that the requested services are medically necessary. Based on this information, we decided that Medicare 
rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a rhizotomy procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit for a bilateral duplex scan provided to the 
enrollee on June 20, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Medicare rule for payment of this date of service June 20, 2022 claim has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93926 is "Duplex scan of lower extremity arteries or 
arterial bypass grafts; unilateral or limited study." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the MUE for this procedure code 
is one, and this code was billed twice in the same encounter. This is not in accordance with coding guidelines. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit for a bilateral duplex scan provided to the enrollee on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography/computed tomography 
(PET/CT). 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the additional information available, the request does not meet the Medicare or 
health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
malignant melanoma stage pt1a right forearm. PET/CT is not indicated or covered for malignant melanoma 
less than Stage III or higher as an initial staging procedure. Additionally, the National Comprehensive Cancer 
Network (NCCN) do not support imaging at this stage. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography/computed tomography (PET/CT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve advanced prosthetic knee and foot system. 
 
You asked the Plan to pre-approve advanced prosthetic knee and foot system. You say that these items are 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the record does 
not support that the enrollee would be a K3 ambulator as required for the advanced foot and knee system. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. 
 
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 advanced prosthetic knee and foot 
system. Our reviewer says that the requested advanced prosthetic knee and foot system is not medically 
reasonable and necessary. Our physician reviewer found the request equipment is for a person who will 
ambulate at the K3 level. The medical records indicate that you will need to traverse curbs and walk on grass. 
The documentation confirms this is a level 2 ambulation need. You currently rely on a walker for limited 
community walking. In this case, the record confirms that you would not be a K3 functional ambulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advanced prosthetic knee and foot system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve advanced prosthetic knee and foot system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correcting function of intraocular lens 
provided on July 29, 2022. 
 
You asked the Plan to pay for the services provided. You say that the doctor told you that you needed this lens. 
The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting 
function of intraocular lens provided on July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient services you received on 
June 22, 2022, and June 23, 2022. 
 
You asked the Plan to waive the cost share. You say that you thought this would be covered 100%. 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 you must pay a $20 
copayment for physical therapy services and a $175 copayment for outpatient surgery. 
 
Review of the file shows that you were provided outpatient surgery and physical therapy on June 22, 2022, and 
June 23, 2022. You have been asked to pay a $20 copayment for the physical therapy services and a $175 
copayment for the surgery services. 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 outpatient 
services you received on June 22, 2022, and June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation mileage for two trips. 
 
You asked the Plan to provide additional miles. You say that this transportation is necessary. The Plan denied 
your request. The Plan says the requested location is more than 75 miles of driving distance from your home. 
Covered trips must not exceed 75 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation to and from Plan-approved locations within 75 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide additional routine transportation mileage for two trips.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdualag, Dexamethasone, and Ondansetron IV. 
 
You asked the Plan to pre-approve Opdualag, Dexamethasone, and Ondansetron IV. 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. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdualag, Dexamethasone, and 
Ondansetron IV. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
it would not be less effective, and many experts recommend nivolumab and ipilimumab as first line treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdualag, Dexamethasone, and Ondansetron IV have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Opdualag, Dexamethasone, and Ondansetron IV.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit received on August 16, 2021. 
 
You asked the Plan to pay for the visit. You say that you did not keep this appointment. The Plan denied your 
request. The Plan says prior authorization was required. 
 
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 received on August 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the request 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 a continuation of SNF care. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found that daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. There is no documentation that the 
enrollee requires services on an inpatient basis, only in a skilled nursing facility setting. The enrollees care 
needs can, as a practical matter, be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for weakness, hyperkalemia, and acute on chronic kidney 
disease. 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 medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you still need assistance, you want to return home 
but have safety concerns. The Plan denied your request. The Plan says the request 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. Your care needs as a practical matter can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 19, 
2022 to June 17, 2022. 
 
You asked the Plan to pay for SNF care. You say that these SNF services should be paid. The Plan denied your 
request. The Plan says the patient did not require SNF services on the dates of service in question. The patient's 
needs were non-skilled in nature and could have been managed at a lower level of care.  
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 pay for SNF care. Our reviewer says that the SNF 
care was not considered medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found the patient is a 95-year-old female with acute respiratory failure, dementia, pneumonia, and 
congestive heart failure. From a nursing perspective, the patient received oral medications and had stable vital 
signs. Regarding rehabilitation services, the patient received physical and speech therapy and was at a moderate 
assist level for functional mobility including gait to 200 feet. She tolerated a mechanical soft diet and thin 
liquids. The patient had no identifiable skilled nursing needs.  While she did have identifiable skilled therapy 
needs, she did not require therapy on a daily basis in an inpatient SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from May 19, 2022 to June 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to get in and out of bed without 
assistance. The Plan denied your request. The Plan says the request 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that daily 
skilled services are required. There is no documentation that you require the services on an inpatient basis, only 
in a skilled nursing facility setting. You do not meet the severity of illness or intensity of service 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records do not indicate a hospitalization within the past year for heart 
failure. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the CardioMEMS device was approved by the FDA in 2014 and consists of a sensor device placed 
in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with 
CHF. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this patients 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 21, 2022, to 
February 19, 2022. 
 
You asked the Plan to pay for home health services. You say that the home health services were medically 
necessary. The Plan denied your request. The Plan says the provider did not bill as required by Medicare 
coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that the admission date on the NOA must always 
match the from date. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services provided from January 21, 2022, to February 19, 2022.