Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's attending physician's have determined 
that he meets the criteria for IRF care, as he requires intensive inpatient rehabilitation with daily physician 
management, 24-hour specialized rehabilitation nursing, and intensive therapies to optimize mobility and 
strengthening while ensuring the restoration of function status. The Plan denied your request. The Plan says the 
enrollee's therapy needs are being met at the current facility. 
 
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 knee replacement and transferred to skilled nursing on June 18, 2022. 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 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 this 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you received the permanent insurance card and the 
informational booklet during the first week in March. You also say you made an appointment and saw a doctor 
in January. You also say that had you been in possession of your permanent card and insurance booklet, you 
would have been able to notice that the provider practice was not in the network. The Plan denied your request. 
The Plan says this provider is not a network provider with the Plan. 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 office visit provided on January 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen-based wound filler and gauze provided on February 
8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collagen-based wound filler and gauze. You say that the supplies are a separately 
billable expense that does not require separate authorization. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
collagen-based wound filler and the gauze. We found no exception that would require the Plan to pay for the 
collagen-based wound filler and the gauze. Therefore, we decided that the Plan does not have to pay for 
collagen-based wound filler and gauze provided on February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (CPT code(s): 64495, 64494, 
64493). 
 
You asked the Plan to pre-approve the facet joint injections. You say that on physical exam, the enrollee has 
positive axial loading; therefore, bilateral facet L3/4, L4/5, L5/SI was recommended and denied. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
they do not have an absence of untreated back pathology, nor do they have an 80% improvement of the 
enrollee's pain with the first set of injections in January. 
 
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 facet joint injections. Our physician 
reviewer found the enrollee did not achieve 80% pain relief from the first set of MBBs; therefore, the request is 
deemed 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (CPT code(s): 64495, 64494, 64493).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for the magnetic resonance imaging 
(MRI) of the brain (70551) provided on March 2, 2022. 
 
You asked the Plan to waive or reduce the copayment for the MRI. You say that if you had been told you could 
have this service provided at a lower cost to you, you would have gone elsewhere. The Plan denied your 
request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance 
with your contract. The Plan also states that the difference in cost share based on the type of facility is specified 
in the contract. 
 
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 $175 
copayment for Medicare-covered diagnostic radiology services provided in an outpatient facility.  
 
You have been asked to pay a $175 copayment for the MRI. An MRI falls within the Medicare-covered 
diagnostic radiology services benefit category, and in this case the MRI was performed in an outpatient hospital 
setting. 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 or reduce the copayment for the magnetic resonance imaging 
(MRI) of the brain (70551) provided on March 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not being prescribed for a medically accepted 
indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 
requested drug, Retacrit, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the reviewer found that the requested drug 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says ample time 
has been provided to establish a home exercise program. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health physical therapy 
services. Our physician reviewer found that the enrollee is able to accomplish bed mobility and transfers 
without hands on assistance. She can ambulate up to 100 feet with a wheeled walker without hands on 
assistance. The enrollee does not require additional skilled rehab services to effectively provide treatment to 
improve her condition or perform a maintenance program to maintain her condition or prevent deterioration. 
She has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. Therefore, the requested home health services are not medically 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 additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health physical therapy services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic facet blocks (CPT code(s): 64494 and 64493). 
 
You asked the Plan to pre-approve diagnostic facet blocks. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that there is no documentation of two diagnostic facet joint 
procedures being performed. The Plan states they have made multiple unsuccessful attempts to reach the 
provider and gather additional information to verify that the provider is requesting therapeutic not diagnostic 
facet injections. The Plan states the reviewer has made four of these attempts; therefore, the Plan cannot say 
this procedure is reasonable or necessary at this time. 
 
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 diagnostic facet blocks. Our physician 
reviewer found the appeal letter states these are diagnostic facet blocks. Therefore, the request is deemed 
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 diagnostic facet blocks have been met. Therefore, we decided that the Plan has 
to pre-approve diagnostic facet blocks (CPT code(s): 64494 and 64493).   
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: 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 clinical information provided supports the need 
for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. 
The Plan says that the enrollee's medical condition requires further care in the acute care hospital. The Plan 
says that the enrollee needs to stay in the hospital until they are better. 
 
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 sepsis, colitis, and knee pain. 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 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 this 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 00732 provided on January 10, 
2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed as required by 
Medicare coding regulations. 
 
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 anesthesia services coded 00732 provided on January 10, 2022, have been met. In this case, the Plan has sent out several requests for medical 
records to confirm the services as billed. No records were received to corroborate the billed claim. Therefore, 
we decided that the Plan does not have to pay for the anesthesia services coded 00732 provided on January 10, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care, first hour, (99291) provided on January 5, 
2022. 
 
You asked the Plan to pay for the critical care. You say that the enrollee was seen prior to the time that the 
hospice election took place. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. 
Additionally, the hospice election is not time specific and covers the entire date. Therefore, we decided that the 
Plan does not have to pay for the critical care, first hour, (99291) provided on January 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 89 additional units of ambulance mileage (A0425) billed for 
date of service, November 13, 2021. 
 
You asked the Plan to pay for ambulance mileage. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says this service was not billed according to Medicare 
regulations. Only 250 units of A0425 may be reported per line; additional units require additional lines with an 
appropriate modifier. The Plan must follow Medicare rules. Medicare rules say that an MAI of 1 indicates that a claim line edit 
exists. Additional units may be reported on additional lines, but each line of a claim with the same 
HCPCS/CPT code will be adjudicated separately against the MUE value for that code. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed a total of 339 
units of this code on a single line, exceeding the MUE by 89. Based on this information, we decided that 
Medicare rules for coverage of ambulance mileage have not been met at this time. Therefore, we decided that 
the Plan does not have to pay for 89 additional units of ambulance mileage (A0425) billed for date of service, 
November 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12013 billed for date of service November 
24, 2021. 
 
You asked the Plan to pay for procedure code 12013. You say that the enrollee went to the emergency room 
and was seen by the physician for a medically necessary procedure. You say that the claim should reprocess to 
pay this procedure code. The Plan denied your request. The Plan says payment for code 12013 is bundled into 
payment for code 21310.  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, we have confirmed that code 12013 
is a column II code to column I code 21310. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 12013 billed for date of service November 24, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hip injections (CPT code 20610). 
 
You asked the Plan to pre-approve the hip injections. You say that the services are necessary. The Plan denied 
your request. The Plan says you have a network primary care physician (PCP) who is responsible for providing 
your health care needs an overseeing your care. The Plan states if you need certain types of covered services or 
supplies from network providers, you must get approval in advance from your PCP (such as giving you a 
referral). The Plan states they reached out to your current PCP; however, they did not receive an order with 
CPT codes indicating side of injection and medication to be used. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 hip injections have been met. There 
is no documentation provided to verify where the injection needs to be administered or what type of medication 
is to be used. Therefore, we decided that the Plan does not have to pre-approve the hip injections (CPT code 
20610).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a series of 3 Euflexxa injections (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has had numerous corticosteroid 
injections with some benefit. You say that the enrollee has noted decreased efficacy over the last several 
months. You also say that the injections are being requested to treat the enrollee's arthritis. The Plan denied 
your request. The Plan says the requested injections are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Euflexxa. Our reviewer says that the 
request for a series of 3 Euflexxa injections is not medically necessary. Our physician reviewer found the 
provided documentation does not indicate the enrollee has radiographic evidence (x-ray or MRI) of osteophytes 
in the knee joint, sclerosis in bone adjacent to the knee, or joint space narrowing. The reviewer found that the 
requested use of Euflexxa is not FDA-approved for the enrollees diagnosis. The reviewer also found that 
without a definitive diagnosis, the requested Euflexxa injections are not medically appropriate 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a series of 3 Euflexxa injections (J7323).