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 needs IRF care in order to have 
successful healing and life. The Plan denied your request. The Plan says the guidelines for coverage have not 
been met. The Plan says that the enrollee could receive the care needed in another 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. The documentation is also not 
clear that she can tolerate an intensive level of rehabilitation given the therapy notes indicating that she was 
limited by feeling dizzy during therapy. 
 
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 pre-approve an office visit (99213) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that it should be important since you need to get a 
prescription for the eyeglasses. You also say that you are informed that you are only covered for urgent and 
emergency care, and it should be something that is considered as an emergency. The Plan denied your request. 
The Plan says the requested provider is not part of the Plan network, and it is outside of the service area. The 
Plan also says that these services can be received from providers in the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99213) to be provided by an out-of-network (OON) provider.
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 without this inpatient stay you are concerned that the 
enrollee's medical needs will not be managed well at a lower level of care. The Plan denied your request. The 
Plan says the 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 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. Our reviewer 
found that the documentation does not support that the enrollee requires at least 3 hours a day, 5 days a week, 
or 15 hours over 7 consecutive days, of therapy services. Our physician reviewer also found that the enrollee 
would likely 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 office visit provided on June 18, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were 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 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 the office visit provided on June 18, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided November 2, 2021. 
 
You asked the Plan to pay for the periapical x-ray. You say that your provider said the insurance company 
indicated the x-ray would be covered. The Plan denied your request. The Plan says this service is not covered 
under your 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 pay for the 
intraoral - periapical first radiographic image (D0220) provided November 2, 2021.  
 Your complaint about potentially receiving misinformation from your provider or plan representative is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound of the breast (76641) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve ultrasound of the breast. You say that this service was declined despite your 
family history and despite all mammogram reports. The Plan denied your request. The Plan says the requested 
provider is not in-network, however, there is a provider recommended in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
ultrasound of the breast (76641) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on 
October 14, 2021. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you disagree with the denial. You 
also say that this should be covered as it is similar to having a skin cancer screening or a mammogram. The 
Plan denied your request. The Plan says the requested service is not a covered benefit with your Plan. 
 
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 pay for an 
adjunctive pre-diagnostic test (D0431) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the records provided support the need 
for a spinal cord stimulator. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary because the records do not show a condition for which a spinal cord stimulator is covered. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are covered for certain 
medical indications. 
 
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 spinal cord stimulator. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found detailed documentation is 
not evident regarding this requested stimulator being the last resort. Trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures is not evident on documentation provided for review. 
Documentation is not evident regarding chronic pain that is caused by lumbosacral arachnoiditis that has not 
responded to medical management including physical therapy; any intractable pain caused by nerve root 
injuries, post-surgical or post-traumatic including that of post-laminectomy syndrome (failed back syndrome); 
intractable pain caused by complex regional pain syndrome I & II; intractable pain caused by phantom limb 
syndrome that has not responded to medical management; intractable pain caused by end-stage peripheral 
vascular disease when the patient cannot undergo revascularization or when revascularization has failed to 
relieve painful symptoms and the pain has not responded to medical management; intractable pain caused by 
post-herpetic neuralgia; intractable pain caused by plexopathy; intractable pain caused by intercostal neuralgia 
that did not respond to medical management and nerve blocks; intractable pain caused by cauda equina injury; 
or intractable pain caused by incomplete spinal cord injury. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for an office visit. You say that this provider is one of the most respected, 
conservative, orthopedic surgeons in the Southeast. You also say that this provider is on the Plan's list of 
approved physicians, so you do not understand this denial for an assessment. The Plan denied your request. The 
Plan says this provider is not contracted with the Plan and services are available in-network. 
 
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 
(99214) by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on October 23, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 70450 
is a column II code to column I code 70496. 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 the services (70450) provided on October 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on October 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). 
Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 
76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that 
the Plan does not have to pay for the abdominal ultrasound rendered on October 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half 
leg (E0673) provided July 8, 2021. 
 
You asked the Plan to pay for the pneumatic appliance. You say that the doctor felt it was medically necessary 
for the enrollee to use the DVT. Please review attached records and process this for payment without further 
delay. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers.  
In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for the 
segmental gradient pressure pneumatic appliance, half leg (E0673) provided July 8, 2021.
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 you feel that the enrollee requires inpatient therapy and disagree with the Plan's decision to send them to a SNF. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.
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 documentation does not support that the enrollee requires 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 IRF admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Romiplostim rendered on January 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the claim should be paid at 63 units instead of 75 units. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the smallest vial size to produce the enrollee's dose is one 
500 mcg and 125 mcg vials, for a total of 600 mcg, and the smallest vial size to produce the dose is 63 units, 
including waste. The Plan has not provided any documentation to support the dosage as listed. Therefore, we 
decided that the Plan has to pay for the Romiplostim rendered on January 20, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an upcoming computed tomography (CT) 
scan. 
 
You asked the Plan to waive the copayment for the CT scan. You say that this is too expensive, and you cannot 
afford it. The Plan denied your request. The Plan says the appropriate cost sharing of $350 will apply for CT 
scans. 
 
  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 $350 
copayment for diagnostic radiology services (other than ultrasounds).  
 
You have been asked to pay a $350 copayment for the CT scan. The CT scan falls within the diagnostic 
radiology services (other than ultrasounds) benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an upcoming computed tomography (CT) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the closed treatment of a radial head or 
neck fracture (24650) and the hospital outpatient clinic visit (G0463) provided on August 25, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $270 
copayment for surgery services provided at an outpatient hospital.  
 
 
 You have been asked to pay $246.48 for the surgery provided at an outpatient hospital. This is the Plans 
allowed amount for this service which is less than the applicable copayment. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the closed treatment of a radial head or neck fracture (24650) and the hospital 
outpatient clinic visit (G0463) provided on August 25, 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. The Plan denied your request. The Plan says IRF admission is not 
medically necessary. 
 
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 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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.