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

 
We decided that the Plan does not have to pre-approve 53 visits for Ferumoxytol, for treatment of iron 
deficiency anemia, 1 mg (for ESRD on dialysis), injection (Feraheme) (Q0138). 
 
You asked the Plan to pre-approve the iron infusions. You say that the medical records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says the records do not support that 
this service is medically needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the iron infusions. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the record indicates that the enrollee has a diagnosis of unspecified iron 
deficiency. The records provided do not provide laboratory evidence of iron deficiency anemia and do not 
demonstrate that the enrollee is intolerant to or have had an unsatisfactory response to oral iron. The Food and 
Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. The elements of the coverage criteria are not satisfied, and the requested service 
cannot be recommended. 
 
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 iron infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve 53 visits for Ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on 
dialysis), injection (Feraheme) (Q0138).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the drugs for prostate cancer provided on May 16, 
2022, to May 23, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you must get these drugs every 
three months and the price keeps going up. The Plan denied your request. The Plan says that the cost-sharing 
amount you are being charged is correct. 
 
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 did not provide an Explanation of Benefits (EOB) or the payment 
information for these claims. Without this information we are unable to determine if the cost sharing amount 
was applied correctly. Therefore, we decided that the Plan has to waive the coinsurance for the drugs for 
prostate cancer provided on May 16, 2022, to May 23, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on May 31, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you feel this is outrageous because the 
hospital is only 12 miles away from your house. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $325 
copayment for Ambulance services.  
 
You have been asked to pay $325 copayment for ambulance. This item/service falls 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 provided on 
May 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 10-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you cannot afford the cost of 
transportation. The Plan denied your request. The Plan says you have exhausted your routine transportation 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that 10 routine transports have been covered. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 10-trip limit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on March 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the services are inclusive to another procedure. 
 
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, the CPT Code Manual definition of code 75726 is angiography, visceral, selective or 
supraselective (with or without flush aortogram), radiological supervision and interpretation. The CPT Code 
Manual definition of code 75774 is angiography, selective, each additional vessel studied after basic 
examination, radiological supervision and interpretation (List separately in addition to code for primary 
procedure). 
 The file shows that a vascular embolization,  inclusive of all radiological supervision and interpretation, 
intraprocedural road mapping, and imaging guidance necessary to complete the intervention, was provided. We 
find that CPT codes 75726 and 75774 are not separately reportable when provided as part of a vascular 
procedure. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the imaging services provided on 
March 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for a surgical spinal injection 
provided on May 25, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for outpatient surgery. You say that you believe 
you shouldn't have to pay more than the $20 copay. The Plan denied your request. The Plan says this cost 
sharing was charged 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 10% 
coinsurance for the approved amount, after you meet your annual deductible of $200, for outpatient surgery at 
an ambulatory surgical center. At the time this claim was processed, $0 of the $200 deductible had been met. The allowed amount of the claim is $310.98, resulting in a deductible amount of $200 which meets the annual 
deductible for 2022. After the deductible is met, the remaining allowed amount of the claim is $110.98, 
resulting in a coinsurance amount of $11.10. Therefore, your total cost-sharing amount is $211.10. 
 
You have been asked to pay $200 deductible and 10% coinsurance for outpatient surgery. This item/service 
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 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 deductible and coinsurance for a surgical spinal 
injection provided on May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has respiratory failure, recent covid 19 
and has had pneumonia. The enrollee would benefit from IRF. The Plan denied your request. The Plan says the 
request is not medically necessary, the services the enrollee needs can be provided safely in other settings, for 
example, a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair (E1038). 
 
You asked the Plan to pre-approve a transport chair. You say that the wheelchair you were provided with does 
not allow you to transfer yourself using your leg and arm. You also say the weight of the wheelchair prevents 
you from being able to use it to get to medical appointments. If you stay in the chair you were provided with, 
then you cannot move around the house on your own. This means, you would be bed bound and that would 
cause you to have serious health and welfare complications. The Plan denied your request. The Plan says you 
have the same or similar DME in good and functional condition that is less than 5 years old. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you were approved for a standard wheelchair (K0001) from April 29, 2021, to May 29, 
2022. A standard wheelchair serves the same purpose as a transport chair. Therefore, we decided that the Plan 
does not have to pre-approve a transport chair (E1038).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 27, 
2021. 
 
You asked the Plan to waive the copayment for glycosylated hemoglobin test. You say that you are receiving a 
bill from over a year ago. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for outpatient diagnostic test and therapeutic services and supplies.  
 
You have been asked to pay $10 copayment for glycosylated hemoglobin test. This item/service falls within the 
outpatient diagnostic test 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 copayment for laboratory services provided on March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214) with a cardiologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you have been a patient of the requested provider 
for over a decade. The provider has personally initiated your baseline care for treatment, performed procedures, 
referred and coordinated with your surgeon and has been performing monitoring and care. You do not trust 
anyone else to pick up where he left off. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. The Plan also says 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 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 
office visits (99204, 99214) with a cardiologist 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the appropriate level of 
care for the enrollee, and she is medically stable. You say that the clinical information provided supports this 
need. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this time 
because they still require a noninvasive mechanical breathing machine intermittently throughout the day. 
 
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 enrollee was admitted with fungal pneumonia in the setting of recent Covid-19 
infection.  The record indicates that the enrollee has ongoing acute medical issues and still requires acute care 
services.  The enrollee continues to receive acute care services and these have not been denied.  The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON physical therapy. You say that the patient has cerebral palsy and 
has been going to this physical therapist for 10 years and has built a good relationship with them. The Plan 
denied your request. The Plan says physical therapy 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 provider at issue in this case is not a network provider with the Plan. 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 OON physical therapy. Our reviewer says that continued physical 
therapy with the out-of-network provider is not medically necessary. Our physician reviewer found the 
enrollee's medical needs are not urgent or emergent and appropriate services are available from in-network 
providers. No unique therapy services are being provided, so there is no need to use this out-of-network provider. 
 
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 OON physical therapy have not been met.  
 
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 the OON physical therapy. Therefore, we decided that 
the Plan does not have to pre-approve physical therapy 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says admission to IRF was denied as not meeting AIR criteria, not medically 
necessary, and a lower level of care might be appropriate. SNF level of care was offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.