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

 
We decided that the Plan does not have to reduce the deductible for DME provided on March 10, 2022. 
 
You asked the Plan to reduce the deductible for DME. You say that you paid too much and would like to be 
reimbursed. The Plan denied your request. The allowed amount is $15.36 which is being applied to the 
deductible and the plan will only process claims according to that allowed amount. The Plan says the 
deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,500 deductible which applies to Durable medical equipment 
(DME) and related supplies.  
 
The item or service you asked the Plan to reduce the deductible for falls within the benefit category Durable 
medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $1,500 deductible which applies to Durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time DME was received on 
March 10, 2022. Therefore, we decided that the Plan does not have to reduce the deductible for durable medical 
equipment (DME) provided on March 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you are allergic to many medications. The Plan denied 
your request. The Plan says you must try an intravenous (IV) bisphosphonate. 
 
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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial 
of at least one bisphosphonate before they will approve the requested drug. While there is an indication that an 
oral bisphosphonate may not be well tolerated by you due to gastrointestinal issues, there is no specific 
indication that intravenous zoledronic acid would likely be less effective or likely have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that SNF care is necessary in this case. The 
Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services. 
 
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 the SNF admission. Our reviewer says 
that the requested SNF care is not medically reasonable and necessary. Our physician reviewer found the 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. The enrollee is not shown to have a significant decline in function. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs are custodial and intermittent and 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for speech therapy provided from October 10, 
2021, to November 2, 2021. 
 
You asked the Plan to waive the copayment for speech therapy. You say that these services were never 
authorized. The Plan denied your request. The Plan says the copayments applied are 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 $40 
copayment per therapy type, per provider, per day for physical and speech services.  
 
You have been asked to pay $520 ($40 x 13 visits) copayment for speech therapy. Speech therapy falls within 
the Outpatient Rehabilitation Services 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 
speech therapy provided from October 10, 2021, to November 2, 2021.
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 physicians are saying that inpatient therapy is 
medically necessary. The Plan denied your request. The Plan says the enrollee can safely receive the services 
they need in other 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 that in this case, the complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain your functional status. You can receive further services 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 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: 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 this is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a lower level of care when the enrollee is 
stable for transfer. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services  are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72110-26 billed for date of service February 
9, 2022. 
 
You asked the Plan to pay for procedure code 72110-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 72110-26 is bundled into 
payment for code 72082. 
 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 
72110-26 is a column II code to column I code 72082. 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 72110-26 billed for date of service 
February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injections do 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injections. Our 
reviewer says that epidural steroid injections are not medically necessary. Our physician reviewer found the 
Medicare LCD requires 3 months of at least 50% pain relief. 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography, of the maxillofacial area; without 
contrast material (70486) rendered by the out-of-network (OON) provider on November 5, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the computed tomography, of the maxillofacial area; without contrast material (70486) 
rendered by the out-of-network (OON) provider on November 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmic ultrasound provided on March 
10, 2022. 
 
You asked the Plan to waive the copayment for ophthalmic ultrasound. You say that you received this service 
at a specialists office which is supposed to have a $0 copayment. The Plan denied your request. Although the 
ultrasound is a type of diagnostic radiology, it is not as advanced as an MRI or CT scan. Therefore, the member 
was not billed $75. The $10 copay for radiology is applicable to ultrasounds. 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 $10 
copayment for ultrasounds.  
 
 
 
 You have been asked to pay $10 copayment for ophthalmic ultrasound. Ophthalmic ultrasounds 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 ophthalmic ultrasound provided on March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376-26 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 76376-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 76376-26 is bundled into 
payment for code 78306. 
 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 
76376-26 is a column II code to column I code 78306. 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 76376-26 billed for date of service 
March 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery provided on July 16, 
2021, to January 25, 2022. 
 
You asked the Plan to waive the copayments for outpatient surgery. You say that you keep having to have 
surgery so it should be covered. The Plan denied your request. The Plan says the copayments applied are 
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 $350 
copayment per day for other outpatient procedures and services.  
 
 
 You have been asked to pay $1,050 ($350 x 3 surgeries) copayment for outpatient surgery. Outpatient surgery 
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 copayments for outpatient 
surgery provided on July 16, 2021, to January 25, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is 
not shown to be able to tolerate fifteen hours per week of rehabilitative services with 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast MRI. 
 
You asked the Plan to pre-approve a breast MRI. You say that a breast MRI is medically necessary. The Plan 
denied your request. The Plan says a breast MRI does not meet Plan's Medical Policy coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a breast MRI. Our reviewer says that 
the requested breast MRI is not considered medically reasonable and necessary. Our physician reviewer found 
that the provided records do not document that you received radiation to the chest between ages 10 and 30, 
have a genetic predisposition to breast cancer, in either themselves or a first-degree due to Bannayan-Riley-
Ruvalcaba syndrome, BRCA1 and BRCA2 mutations, Cowden syndrome or Li-Fraumeni syndrome (TP53). 
The medical records do not document that you have a genetic mutation (ATM, CDH1, CHEK2, PALB2, NBM, 
NF-1 or PTEN). The records do not document that you have a history of lobular carcinoma in situ (LCIS), 
atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH) on biopsy. The records do not 
document that you have a lifetime breast cancer risk of 20% or greater as defined by the GAIL model, 
BOADICEA, BRCAPRO, Claus,Tyrer-Cuzick or other models that are largely dependent on family history.  
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 breast MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a breast MRI.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer (iron sucrose) 200 mg/10ml Vial every week 
for 8 visits. 
 
You asked the Plan to pre-approve Venofer every week for 8 visits. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Venofer every week for 8 visits. Our 
reviewer says that the documentation does not support that the requested drug is medically reasonable or 
necessary. Our physician reviewer found the enrollee has iron deficiency anemia. Based on the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that the Venofer 200 mg 
each week for 8 weeks meets Medicare criteria for medically reasonable and necessary. The cumulative 
requested Venofer dosage (1600 mg) exceeds the standard cumulative maximum dose (1000 mg) as detailed in 
the Medicare-approved major drug compendia. Therefore, the requested dosage is 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 Venofer every week for 8 visits. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Venofer (iron sucrose) 200 mg/10ml Vial every week for 8 visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Implantable Loop Recorder (33285). 
 
You asked the Plan to pre-approve the Implantable Loop Recorder. You say that the loop recorder is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an Implantable Loop Recorder is used when syncope 
is thought to be cardiac related, but is too infrequent to be detected by either a Holter monitor or a traditional 
pre-symptom loop recorder. 
 
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 Implantable Loop Recorder. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has paroxysmal atrial fibrillation without a history of syncope. The elements of the coverage 
rules are not 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 the Implantable Loop Recorder have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an Implantable Loop Recorder (33285).