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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While you do need physical and/or occupational therapy, there is no documentation of a need for and ability to 
tolerate an intensive rehabilitation 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 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 pay for subsequent nursing facility care (99308) provided on June 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing care. You say that the Plan did not have any contracted 
providers at this facility to provide services. The Plan denied your request. The Plan says out-of-network care is 
covered only in certain limited circumstances. The requested services were not urgent/emergent or pre-
approved. The Plan had in-network providers and facilities who could have rendered medically necessary 
services. 
 
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 subsequent nursing facility care (99308) provided 
on June 8, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain without 
contrast material (70450) provided on August 29, 2021. 
 
You asked the Plan to pay for the CT scan. You say that this service was medically necessary. The Plan denied 
your request. The Plan says information from the primary insurer is required to process this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to the primary insurer for payment. As the secondary insurer, the Plan cannot be held responsible for 
the CT scan until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for computed tomography (CT) of the head or brain without contrast material 
(70450) provided on August 29, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 10, 2021, to 
September 19, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services should be covered. The 
Plan denied your request. The Plan says that the services are not supported. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 10, 2021, to September 19, 2021.  
 
 
 
 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0452) provided January 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage rules were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The records show the tests were not ordered by the enrollee's 
attending physician. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0452) provided 
January 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via Disc injection of allograft material. 
 
You asked the Plan to pre-approve the Via Disc injection. You say that you feel that this should be allowed. 
The Plan denied your request. The Plan says this treatment is experimental at this time. 
 
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 Via Disc injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this 62-year-old female has chronic low back pain. Her imaging shows degenerative 
changes at 2 levels with the discs abutting nerve roots. The request is the injection of Via Disc allograft 
material. The patient is not enrolled in a clinical trial. 
 
This is an experimental/ investigational procedure. Therefore, the request is considered 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 Via Disc injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Via Disc injection of allograft material.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 rapid test purchased on January 11, 2022. 
 
You asked the Plan to pay for the COVID-19 rapid test. The Plan denied your request. The Plan says that you 
purchased this COVID-19 test prior to when coverage of these tests began. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans must provide you with a clear and 
accurate description of the benefits offered under the plan. This description must include any conditions, 
limitations, premiums or cost sharing associated with the benefit. 
 
We looked at the file and Medicare rules. The record shows that you purchased an at home COVID-19 test, and 
the Plan denied saying this item was not covered prior to February 1, 2022. The 2022 Evidence of Coverage 
does not mention this criteria, nor does it mention anywhere you should look to find this criteria. You 
reasonably believed this item would be covered because it is not listed as a non-covered benefit. Based on this 
information, we decided that Medicare rules for coverage of the COVID-19 rapid test have been met. 
Therefore, we decided that the Plan has to pay for the COVID-19 rapid test purchased on January 11, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second facet joint injection. 
 
You asked the Plan to pre-approve the second injection. You say that this should be approved due to medical 
necessity. The Plan denied your request. The Plan says a second injection is not covered if the first injection 
provided no relief. 
 
The Plan must follow Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary in patients who received a primary facet joint 
injection and had a consistent positive response of at least 80% relief of primary (index) pain. 
 
We looked at the file and Medicare rules. The facet joint injection provided prior to this request produced no 
pain relief. A secondary injection is not covered in this circumstance. Based on this information, we decided 
that Medicare rules for coverage of the second injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a second facet joint injection.
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 the member needs admission to LTACH. 
The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 The patient appears to be stable and improving and requires only short-term 
additional acute care hospital services that can safely be administered at the current facility until more 
appropriate for a lower level of care. The patient does not require services at the LTACH that are not already 
available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 19, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 October 19, 2021 by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided in an 
outpatient setting from February 18, 2022, to February 20, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not know self-administered 
drugs were not covered when in the hospital. You say that you did not have time to collect your medications 
before entering the hospital. You also say that you should not have to pay for this. The Plan denied your 
request. The Plan says the services denied correctly. 
 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 pay for the self-administered drugs 
(A9270) provided in an outpatient setting from February 18, 2022, to February 20, 2022.  
 
Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) purchased on December 30, 2021 from 
an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the frames. You say that the ophthalmology office does not provide eyeglasses. 
The Plan denied your request. The Plan says the provider is OON, there is no pre-authorization, no referral 
from the primary physician, and no medical emergency. The Plan also says that there are more than 20 contract 
providers in your area. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you have an authorization for OON covered services. 
 
We looked at the file and the Plan's rules. The record shows that you received this service from an OON 
provider, and did not obtain an authorization. Based on this information, we decided that the Plan's rules for 
coverage of the frames have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames (V2020) purchased on December 30, 2021 from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the  injection and procedure provided on 
January 12, 2022. 
 
You asked the Plan to waive the cost share for the  injection and procedure. You say that your copayment 
should cover the total cost. The Plan denied your request. The Plan says the cost share 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 $120 
copayment for radiological or diagnostic services and 20% coinsurance for Medicare covered Part B drugs. 
 
 You were asked to pay $80.79 which is less than the standard $120 copayment for radiological and diagnostic 
services. You were also asked to pay $1.13 which is 20% of the allowed amount for the injection. The allowed 
amount is $5.63(20% x $5.63=$1.13). The total amount you must pay is $81.92 for the injection and procedure.  
Injections fall within the Medicare Part B Prescription Drugs benefit category. The procedure falls 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 cost share for the injection and procedure provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that there is a referral number for 10 visits on file for this 
date of service. The Plan denied your request. The Plan says this provider is not a network provider with the 
Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan 
also says they have 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 February 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 4, 
2020. 
 
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 you never received a bill for this. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until April 7, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for imaging services provided to the enrollee on January 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on February 12, 
2021. 
 
You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Based on this information, we 
decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided 
that the Plan does not have to pay for therapeutic exercises (97110) provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthoses billed for date of service January 4, 2022. 
 
You asked the Plan to pay for the knee orthoses. You say that You did not provide a specific argument with 
your appeal request. The Plan denied your request. The Plan says you did not provide a valid packing slip or 
proof of delivery for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery with itemized product listing for the supplies provided in 
this case. [ADJUDICATOR-IDENTIFY REASONS FOR INVALIDITY]. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for knee orthoses billed for date of service January 4, 2022.