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

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest, abdomen, and 
pelvis with contrast (71260, 74177). 
 
You asked the Plan to pre-approve a CT scan of the chest, abdomen, and pelvis with contrast. You say that the 
CT scan is medically necessary. The Plan denied your request. The Plan says that the enrollee's healthcare 
provider states that the enrollee has weight loss, and the cause is unclear. The request cannot be approved 
because the records do not show that results of a thorough workup failed to reveal the cause of her weight loss. 
 
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, abdomen, and 
pelvis with contrast. Our reviewer says that the service is medically necessary. Our physician reviewer found 
the enrollee had a negative Cologuard test on 10/22/22 as well as a negative chest x-ray on 10/20/22. She is on 
hormone replacement therapy. Standard workup including blood work has failed to show the reason for the 
weight loss. Due to her history and standard workup, the criteria for the requested CT chest, abdomen and 
pelvis have been met. 
 
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, abdomen and pelvis with contrast have been met. 
Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest, 
abdomen, and pelvis with contrast (71260, 74177).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/investigational procedure. The request is 
therefore considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
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 you will need at least the 25 days of 
rehabilitation to be able to sit and walk again. The Plan denied your request. The Plan says the member is 
receiving appropriate in-patient acute care and is currently unstable for transfer for transfer to an LTACH. 
 
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 medical records do not indicate that the enrollee requires services that he 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot receive the 
appropriate level of nursing care in a lower level of care. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements. 
 
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 is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for hip replacement surgery. Medical problems are stable. There 
are 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 the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that he meets 
the criteria for admission to an acute inpatient rehabilitation facility. The enrollee can receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine, 
without contrast (72141). 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that you disagree with the denial. The 
Plan denied your request. The Plan says that the request cannot be approved because imaging requires six 
weeks of provider directed treatment to be completed. There was no contact with your provider after 
completing treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the cervical spine. Our 
reviewer says that the service is medically necessary. Our physician reviewer found Medicare regulations state 
that MRIs are eligible for coverage when they are reasonable and necessary. In this case, you reported bilateral 
upper extremity weakness. On exam, you were also noted to have weakness with grip bilaterally (per the chart 
notes). In such a setting, imaging of the cervical spine would be appropriate given the findings on examination 
and associated complaints. This would meet the threshold of being "reasonable and necessary" and would be 
eligible for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine, without contrast (72141).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found records do not document the need for intravenous medications, new 
tube feeding, ostomy care, daily complex wound care or respiratory care. There is no documentation that 
further daily skilled services are required. Although records document you are very limited functionally, 
provided records do not document a significant decline in your functional status compared to your recent 
baseline (or improvement with therapy already provided) to necessitate further daily inpatient skilled therapy 
services.  You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not support that services in the home or an assisted living facility with home health care or in a 
long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis provided to the enrollee on April 20, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this should be paid for. The Plan denied your request. 
The Plan says this was medically necessary. 
 
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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not had a recent injury or surgical procedure on the knee. The enrollee is ambulatory 
but does not have objective physical exam findings of joint laxity (e.g., varus/valgus instability, 
anterior/posterior Drawer test). Additionally, the medical progress notes request an L1833 and the knee 
orthosis in appeal is the L1843. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis provided to the enrollee on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for retina imaging provided on March 21, 
2022. 
 
You asked the Plan to waive the copayment for retina imaging. You say that you are being incorrectly assessed 
an out-of-network copayment. 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 a $0 or 
$30 copayment for in-network examinations to diagnose and treat diseases of the eye: $0 for glaucoma 
screenings and diabetic retinal examinations, $30 copayment for all other Medicare-covered vision services.  
 
 
 You have been asked to pay $30 for retina imaging. This item/service falls within the vision care benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
Please note, the records indicate that you received these services from an out-of-network provider, but the Plan 
applied the in-network cost share amount. 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 retina 
imaging provided on March 21, 2022.
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 you would like this reviewed for medical necessity 
for IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
being requested 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 member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician 
reviewer also found that the medically necessary care can be provided on 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Eyelea injections provided on April 28, 
2022. 
 
You asked the Plan to waive the coinsurance for Eyelea injections. You say that the cost of the medication is 
too much. You were getting Avastin, and the provider changed your medication to the Eylea. Your cost 
increased and you are only seeing some improvement at this time. 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 a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this service or item is $3821.92, 
resulting in a coinsurance of $731.36 ($3821.92 x 20% = $731.36). 
 
You have been asked to pay a $731.36 coinsurance for Eyelea injections. This item/service falls within the 
Medicare Part B prescription drugs 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 coinsurance for Eyelea injections provided on April 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee does not need skilled nursing care as the patient requires 
custodial care, not skilled nursing care. 
 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 SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's physical function is at or near the baseline, and services can be received 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 18, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this should be covered. The Plan 
denied your request. The Plan says there was no preauthorization by a primary care provider (this is different 
than a referral) for an OON provider or facility, and this was not an emergency. Therefore, the decision is 
upheld. 
 
 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 a domiciliary or rest home visit provided on 
March 18, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for physical therapy provided from April 12, 
2022, to May 4, 2022. 
 
You asked the Plan to lower the copayment for physical therapy. You say that these copayments are supposed 
to be $5 not $30. 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 a $30 
copayment for outpatient rehabilitation services. $30 x 8 visits = $240 - you are being charged $210 which is 
less than the actual copayment amount. 
 
You have been asked to pay a total copayment of $210 for physical therapy. This item/service falls within the 
outpatient rehabilitation 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 lower the copayment for 
physical therapy provided from April 12, 2022, to May 4, 2022.