Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested CT scan is medically 
necessary. The Plan denied your request. The Plan says the requested CT scan does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the chest. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a history of a pulmonary nodule.  The record indicates that the enrollee had a chest CT angiogram 
in January 2022 that did not demonstrate any nodules. The provided records do not indicate the medical 
necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. 
 
 
 
 
 
 
 
 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 CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee 
does not meet the criteria. 
 
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered for 
specified 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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer 
found the enrollee does not have an evidence-based indication for a spinal cord stimulator trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $10 copayment for laboratory tests performed on 
November 23, 2021. 
 
You asked the Plan to waive the $10 copayment  for laboratory tests performed on November 23, 2021. You 
say that the enrollee should not be responsible for this copayment because the services were rendered while he 
was an inpatient. The Plan denied your request. The Plan says the enrollee pays $10 per day for other 
Medicare-covered laboratory tests that are not FIT tests. 
 
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 the enrollee must pay a 
$10 copay for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 The enrollee has been asked to pay a $10 copay for laboratory tests. Laboratory tests fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on his contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we decided that the Plan does not 
have to waive the $10 copayment for laboratory tests performed on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 18, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulation (FES) device. 
 
You asked the Plan to pre-approve the device. You say that this is needed to alleviate foot drop. The Plan 
denied your request. The Plan says this request falls under the class of experimental and unproven. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to have a history of foot drop and left hemiparesis after a stroke. You have been prescribed 
a FES device for the foot drop. A review of the literature suggests that these devices afford equivalent 
outcomes to the use of ankle-foot orthoses (AFOs) for this indication. The studies done of this technology in 
the patients with stroke have not otherwise shown this technology to have long term net benefit. There is a need 
for further longitudinal studies of the technology as well. Ultimately this requested device would exceed your 
medical needs at this time. 
 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a functional electrical stimulation (FES) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on October 8, 
2021. 
 
You asked the Plan to waive the coinsurance for the chemotherapy. You say that you should not have to pay 
because you met your out-of-pocket maximum in March of 2021. The Plan denied your request. The Plan says 
the coinsurance was applied correctly. 
 
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 20% 
coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug. You pay these 
amounts until you reach the out-of-pocket maximum.  
 
 
  You have been asked to pay $1,045.33, which is less than the standard 20% coinsurance because you met your 
maximum out-of-pocket. The chemotherapy falls within the Medicare Part B Prescription Drugs benefit 
category. The records show a previous claim was adjusted to have you owe $1,045.33 less, which means your 
maximum out-of-pocket had not been met at the time this claim was received. 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 coinsurance for chemotherapy provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an OON office visit. You say that this appointment will help in keeping up 
with and making decisions about the enrollee's peripheral vascular disease. The Plan denied your request. The 
Plan says the requested services can be provided by a network provider. 
 
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 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 level of rehab you will have 
deterioration of function to where you will no longer be able to even get out of bed. The Plan denied your 
request. The Plan says IRF care is not medically necessary, and you can be managed at a lower level of care. 
 
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 he complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for gastrointestinal bleeding and anemia. Your medical problems are stable. and you have no complex nursing or 
rehabilitation needs. 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. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has age related osteoporosis without osteoporotic fracture. The provided records do not 
indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred 
step one alternative. 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Skilled Nursing Facility (SNF) care on 
December 01, 2021, to December 24, 2021. 
 
You asked the Plan to waive the copayments for skilled nursing facility (SNF). You say that they forgot to tell 
you the coverage time was finished. The Plan denied your request. The Plan says a $0 copayment for days 1-
20; $184 copayment per day for days 21-100, per benefit period. You pay this amount until you reach the out-
of-pocket maximum. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital 
or a skilled nursing facility. The benefit period ends when you havent been an inpatient at any hospital or SNF 
for 60 days in a row. 
 
 
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 $184 
copayment for days 21-23 of skilled nursing facility care. There were 23 total days, resulting in a total 
copayment amount of $552.   
You have been asked to pay a $184 copayment for skilled nursing facility (SNF) care. Skilled nursing facility 
(SNF) care falls within the in-network Medicare-covered services. You have a $184 copayment for days 21-23. 
The provider billed the plan $29,071.14. The allowed amount was $14,388.28. The Plan's share $13,836.28. 
Per your benefits, you are responsible for a $552.00 copayment in-network Medicare-covered inpatient skilled 
nursing facility (SNF). This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for Skilled Nursing Facility (SNF) 
care on December 01, 2021, to December 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need such as therapy, can be provided safely 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. You 
are medically stable with no new and acute medical problems and do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified 
or documented in the record. At the current functional level as described above, you do not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. IRF admission is not medically necessary based on medical stability, lack of medical 
complexity, lack of rehab nursing needs and your high functional level. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetic items. 
 You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
items are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications.  
 
We looked at the file, and Medicare rules. The file shows that a below knee alignable system (L5910) was 
requested. The records show that this item was previously approved in April 2021. The records do not show 
that the requirements for a replacement have not been met. The file also shows that a flex foot (L5972) and 
rotation unit (L5986) were requested. The records do not show that these items are beyond repair. Based on this 
information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lower limb prosthetic items.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from July 23, 2021, to August 31, 2021. 
 
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 service at a lower level of care, such as home care or long-term care is appropriate. 
 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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
enrollee no longer qualified for SNF coverage. There were no documented skilled nursing or skilled therapy 
needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration 
of the enrollees condition. The enrollees care needs, custodial and intermittent, could, as a practical matter, be 
provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 23, 2021, to August 
31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided January 31, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that the ambulance should have taken you even 
though you said no. The Plan denied your request. The Plan says since there was no transport, ambulance 
charges are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  The ambulance company did not provide transport services on January 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided January 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee needs to continue therapy 2 
times per week for 4 weeks, for an additional 8 visits and a total of 81 visits since the start of care. The Plan 
denied your request. The Plan says according to the clinical documentation, there is no clinical progress. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the health plan. Our reviewer 
found that the patient has had prior extensive therapy and the documentation does not reveal that the patient's 
functional deficits require the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. Our physician reviewer also found that the requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy (PT) visits.