Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for remote intraoperative neurophysiology monitoring, short-latency 
somatosensory evoked potential study and neurology and neuromuscular procedures, electromyography 
procedures provided on June 14, 2021. 
 
You asked the Plan to pay for remote intraoperative neurophysiology monitoring, short-latency somatosensory 
evoked potential study and neurology and neuromuscular procedures, electromyography procedures. You say 
that the rendering provider participation was beyond control of the patient. The services were requested by the 
in-network provider. The Plan denied your request. The Plan says that the Plans first decision to deny 
coverage for the service was right. 
 
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. Specifically, the Plan has not provided us with the reason for denial of coverage 
of the services. The Plan has not provided us with the network status of the referring provider. Therefore, we 
decided that the Plan has to pay for remote intraoperative neurophysiology monitoring, short-latency 
somatosensory evoked potential study and neurology and neuromuscular procedures, electromyography 
procedures provided on June 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shower chair you purchased on October 22, 2021. 
 
You asked the Plan to pay for the shower chair. You say that you needed this item in order to get better. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for the shower chair you purchased on October 
22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), 
with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in 
addition to code for primary procedure) (CPT code 64636) and destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 
64635). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the enrollee's records do not show that the last procedure improved their pain by at 
least 50 percent (%) for six (6) months or their ability to do their daily activities by at least 50%. The Plan 
states the requested repeat procedure is not supported without this pain relief. 
 
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 services. Our physician reviewer 
found radiofrequency ablation (RFA) pain relief is expected to last at least six (6) months with 12-18 months 
common. The enrollee achieved this duration of pain relief. 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 services have been met. Therefore, we decided that the Plan has to pre-
approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy 
or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) 
(CPT code 64636) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code 64635).  
 
 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (Betadine, Sodium Chloride 
Ointment, Neomycin-Polymyxin-Dexameth Ointment, Acetazolemaide capsules, and Prednisolone Acetate) 
you received following cataract surgeries on October 27, 2021, and November 10, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you are appealing this denial because 
the letter of notice did not provide information as to what items had been denied. The Plan denied your request. 
The Plan says these drugs are not covered under your medical 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 pay for the self-administered drugs 
(Betadine, Sodium Chloride Ointment, Neomycin-Polymyxin-Dexameth Ointment, Acetazolemaide capsules, 
and Prednisolone Acetate) you received following cataract surgeries on October 27, 2021, and November 10, 
2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracic surgery (35301), provided on October 19, 2021. 
 
You asked the Plan to pay for the thoracic surgery. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service was included as part of the global surgical package of the initial 
surgical procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that A/B MACs (B) apply the national definition of a 
global surgical package to all procedures with the appropriate entry in Field 16 of the MFSDB.  The Medicare approved amount for these procedures includes payment for the following services related to the 
surgery when furnished by the physician who performs the surgery. Modifiers were established to simplify 
billing for visits and other procedures which are furnished during the postoperative period of a surgical 
procedure, but which are not included in the payment for the surgical procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the thoracic surgery have not been met. Specifically, this service falls within the 90-day global 
surgery period for CPT code 35301 which was rendered by the same provider. This claim was not submitted 
with the required modifier to indicate that the surgery performed on October 19, 2021, was unrelated to the 
surgery performed on July 22, 2021. Therefore, we decided that the Plan does not have to pay for the thoracic 
surgery (35301), provided on October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on December 3, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not have any self-administered 
drugs in the emergency room or in the hospital. You say that every medication you received was given to you 
by the nurse or EMS. The Plan denied your request. The Plan says the claim 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 
provided in an outpatient setting on December 3, 2021.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are significant cognitive defects that impairs ability to follow instructions. 
 
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 SNF care. Our reviewer says that the 
requested admission is medically reasonable and necessary. Our physician reviewer found the enrollee does 
qualify for SNF coverage, with documented skilled therapy needs. The enrollee is making progress with 
therapy. The records do not yet establish that the enrollee has reached a plateau in function.  Daily skilled 
services are required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a 
skilled nursing facility (SNF) for the enrollee.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from August 15, 2021, to 
September 16, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee was gravely disabled. You also say 
that the enrollee's plan was contacted for skilled nursing facility placement. The Plan denied your request. The 
Plan says the inpatient care was no longer medically necessary on the dates of service in this case. 
 
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 pay for the inpatient care. Our reviewer says that the 
inpatient care was not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided documentation does not indicate the enrollee required or received inpatient level of care 
services for the period August 15, 2021, to September 16, 2021. The reviewer found that the enrollee did not 
require inpatient level of care while they were waiting for an opening in a skilled nursing 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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from August 15, 2021, to September 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
22, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you have never had to pay an 
ambulance copayment before and were not admitted on this day. You also say that you called the Plan before, 
and the previous representative advised you to disregard. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 $75 
copayment for ground ambulance services. The contract says the copayment is waived if you are admitted. 
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$75 copayment for ambulance services. Ambulance services fall within the Ambulance 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 ambulance services provided on December 22, 
2021.
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 SNF services. You say that these services are medically reasonable and 
necessary. The Plan denied your request. The Plan says that you are receiving adequate and necessary intensive 
rehabilitation in the Inpatient Rehabilitation Facility. 
 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that 
the enrollee can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for lumbar laminectomy and fusion. The enrollee's medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 3, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for 
the health of the patient are not a benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the test ordered was to detect urinary pathogens. The record provided is 
insufficient to determine the medical necessity, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmology visit provided on November 9, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the out-of-network ophthalmology visit. You say that you have glaucoma and 
need treatment every six months. The Plan denied your request. The Plan says unauthorized, non-plan care is 
not covered. 
 
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 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 ophthalmology visit provided on November 9, 
2021 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. The Plan denied your request. The Plan says criteria for admission 
to an IRF have 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. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2531), provided on May 5, 2021. 
 
You asked the Plan to pay for the contact lenses. You say that the item is medically necessary. The Plan denied 
your request. The Plan says you have exhausted the Plan's maximum frequency for this item. 
 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 one pair of contact lenses every two years. 
 
We looked at the file and the Plan's rules. The records show you received contact lenses on May 7, 2020, this 
means you have reached the limit for this benefit. Based on this information, we decided that the Plan's rules 
for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay 
for the contact lenses (V2531), provided on May 5, 2021.