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

 
We decided that the Plan does not have to issue reimbursement for a shower chair (E0245), bathtub wall rails 
(E0241x 2), toilet rails (E0243 x 3), and the miscellaneous durable medical equipment (E1399) provided from 
July 31, 2021, through September 28, 2021. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not covered 
under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. Additionally, grab bars are considered self-help items that are not covered 
because they are not primary medical in nature.  
 
While a shower chair and grab bars may be appropriate for you in this case, neither the Plan nor Medicare 
offers coverage of these items.  Therefore, we decided that the Plan does not have to issue reimbursement for a shower chair (E0245), bathtub 
wall rails (E0241x 2), toilet rails (E0243 x 3), and the miscellaneous durable medical equipment (E1399) 
provided from July 31, 2021, through September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13102 billed for date of service December 
20, 2021. 
 
You asked the Plan to pay for procedure code 13102. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 13102 is bundled into 
payment for code 15771. 
 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 13102 
is a column II code to column I code 15771. 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 13102 billed for date of service December 20, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nail debridement performed on February 
16, 2022. 
 
You asked the Plan to waive the copayment for nail debridement performed on February 16, 2022. You say 
that the exact same services were provided in November 2021 and December 2021 and there was no balance 
due. The Plan denied your request. The Plan says you are responsible for the $25.26 copayment for in-network 
specialist services. 
 
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 $35 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $25.26 copayment for nail debridement. Nail debridement falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. Your contract with the Plan 
clearly says that you must pay a $35 copayment for nail debridement. However, you have only been asked to 
pay $25.26 which is less than the copayment amount. 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 nail debridement performed on February 16, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is needed to treat chemotherapy-
induced nausea. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not being used as a full therapeutic replacement for intravenous anti-emetic drugs that 
would have otherwise been administered at the time of chemotherapy treatment. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although prochlorperazine is an oral anti-emetic that may be covered by Medicare Part B, 
this request does not meet Medicare Part B coverage criteria because this drug is not being used as a full 
therapeutic replacement for intravenous anti-emetics. Therefore, we decided that the Plan does not have to pre-
approve prochlorperazine tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections (64484, 64483). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are covered when 
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 injections. Our reviewer says that 
this service is medically necessary. Our physician reviewer found the enrollee has debilitating lumbar 
radiculopathy and has imaging that correlates to the problem. The request 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 the injections have been met. Therefore, we decided that the Plan has to pre-
approve epidural steroid injections (64484, 64483).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal assistant services provided on February 14, 
2022. 
 
You asked the Plan to pay for the personal assistant services. The Plan denied your request. The Plan says 
medical necessity cannot be established because no medical records were provided. 
 
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 personal assistant services 
provided on February 14, 2022. have been met. Medical records were not provided for this case. The record 
shows that the Plan requested medical records multiple times, but they were not provided. Without these 
records, we are unable to determine if the services provided were medically necessary. Therefore, we decided 
that the Plan does not have to pay for the personal assistant services provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 27, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Manual Test precision GU. 
 
You asked the Plan to pre-approve the genetic testing. You say that you would like reconsideration because this 
testing is medically necessary. The Plan denied your request. The Plan says this is not a covered test. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records do not show that the results of this testing will directly impact treatment 
or management of the Medicare beneficiary. Also, the current American Urological Association Guidelines 
state that clinicians should perform an assessment of patient and tumor risk factors to guide the decision to 
offer germline testing that includes mutations known to be associated with aggressive prostate cancer and/or 
known to have implications for 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Manual Test precision GU.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) services. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the skilled nursing facility (SNF) services you are 
requesting do not meet the requirements for approval. 
 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 skilled nursing facility (SNF) services. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there are no 
identifiable skilled therapy service needs the beneficiary does not require skilled nursing or therapy services on 
a daily 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 skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $199.49 deductible applied to an MRI performed on 
March 14, 2022. 
 
You asked the Plan to waive the $199.49 deductible applied to an MRI performed on March 14, 2022. You say 
that you would like the cost share waived as this service was medically necessary. The Plan denied your 
request. The Plan says this cost share was applied correctly. 
 
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 $750 deductible. This is found in the Medical Benefits Chart of the 
Plans 2022 EOC.  
 
 
 
 
 
 The item or service you asked the Plan to waive the deductible applied to falls within the benefit category the 
Medical Benefits Chart. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $750 deductible which applies to an MRI. This cost sharing is a contractual obligation that had not been met 
at the time an MRI was received on March 14, 2022. Therefore, we decided that the Plan does not have to 
waive the $199.49 deductible applied to an MRI performed on March 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are still on oxygen and the blistering on your 
legs requires assistance. You also say you need assistance to get in and out of bed and acute rehab would help 
you gain your strength to do normal activities again The Plan denied your request. The Plan says you do not 
meet the criteria and acute care is not medically necessary. A lower level of care might be appropriate. Skilled 
nursing facility level of care was offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted to an acute hospital on 7/6/22 with COVID-19 pneumonia, septic 
shock and respiratory failure from pneumonia, anemia and generalized weakness. Also, you had acute on 
chronic congestive heart failure and initially intubated until 7/15/22. You were treated for pneumonia and had a 
blood transfusion. You are medically stable and left with debility. Comorbid conditions are all stable. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Taltz injector pen. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
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 Taltz injector pen.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 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 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 patient 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and abutment supported 
crown on tooth #22 (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says custom abutment (D6057) and abutment supported 
crowns (D6058) are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom abutment (D6057) and abutment supported crown on tooth #22 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens (V2781) provided on February 21, 2022. 
 You asked the Plan to pay for the progressive lens. You say that you would like to know why you did not 
receive a full reimbursement for these glasses. The Plan denied your request. The Plan says upgrades are not 
covered, and a prior authorization is needed in order for that to be possible. 
 
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. 
 
We looked at the file and the Plan's rules. The contract clearly states that progressive lenses are not covered by 
the Plan. Based on this information, we decided that the Plan's rules for coverage of the progressive lens have 
not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens (V2781) 
provided on February 21, 2022.
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 the enrollee will benefit from acute rehab to optimize 
his level of function prior to returning home. You say that the enrollee will receive appropriate level of care in 
the acute rehab setting and a further delay in care will have a detrimental effect on the enrollee's ability to 
recover. The Plan denied your request. The Plan says the enrollee does not require an intensive rehabilitation 
program. 
  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 medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation and it is not safe for 
them to go home. The Plan denied your request. The Plan says IRF admission is not medically necessary for 
the enrollee. 
 
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 lumbar decompression surgery. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug will be given for a period exceeding 48 hours from the administration of chemotherapy and is not being used as a full 
therapeutic replacement for intravenous (IV) anti-emetics. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. Although ondansetron is an oral anti-emetic that is covered by Medicare Part B under 
certain circumstances, the requested use of ondansetron does not meet Medicare Part B criteria because it will 
be used for more than 48 hours following chemotherapy administration and is not being used as a full 
therapeutic replacement for intravenous anti-emetics that would have otherwise been administered at the time 
of chemotherapy treatment.. Therefore, we decided that the Plan does not have to pre-approve ondansetron 
tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.