Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for iron treatment provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for iron treatment. You say that you feel that the iron treatment 
should be covered at 100% because this treatment is for your blood disorder. 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 $150 
copayment for outpatient hospital services.  
 
You have been asked to pay $59.17 which is less than the $150 copayment for iron treatment. This item/service 
falls within the outpatient hospital 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 iron treatment provided on June 27, 2022.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 
there are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Health Plan. The Health Plan has approved ongoing care in the current acute care 
setting. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 3 Sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the requested product is considered a non-therapeutic CGM; therefore, the requested 
product was determined not to be reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sensor have not been met. Specifically, the requested CGM device does not meet the definition 
of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided 
that the Plan does not have to pre-approve the FreeStyle Libre 3 Sensor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot walk and do not have anyone to care for 
you. The Plan denied your request. The Plan says a SNF admission is not medically necessary, and your needs 
can be met at a lower level of 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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.

You asked the Plan to pre-approve home health services. You say that the requested services are a medical
necessity for the enrollee. The Plan denied your request. The Plan says the services are not medically
necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

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 home health services. Our reviewer
says that the requested services are not medically reasonable and necessary. Our physician reviewer found that
the enrollee does not have documented skilled nursing needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on September 20, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense and you have an agreement with the facility where the patient was located. The Plan denied your 
request. The Plan says that unauthorized, out-of-network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
February 28, 2022. 
 
You asked the Plan to pay for the moderate sedation services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that for services paid via the PFS, each code is 
assigned both physician work and PE RVUs. PE RVUs are often reduced for physician services rendered in the 
facility setting. Since payment for many PE expenses, such as staff wages and supplies, is included in Medicare 
payment to the facility, payment associated with those resource costs is not made under the PFS. The rules also 
state specifically that nursing services and supplies provided in an ASC are included in the ASC payment rate 
for the procedure. 
 
We looked at the file and Medicare rules. The code 99153 has a Pro/Tech flag of 3 in the PFS. This indicator 
identifies stand- alone codes that describe the technical component (i.e., staff and equipment costs) of selected 
diagnostic tests for which there is an associated code that describes the professional component of the 
diagnostic test only. The total RVUs for technical component only codes include values for practice expense 
and malpractice expense only.  
 
Because code 99153 does not include physician work but reimburse PE RVUs, the services described by this 
code are nursing/technician services and supplies. Payment for this is made to the ASC facility and cannot be 
paid to the physician. As such, payment to the physician for code 99153 in the ASC setting is not allowed. 
Based on this information, the Medicare rules for payment of code 99153 have not been met. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not 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 pre-approve radiofrequency ablation to the SI joint. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has scoliosis. The 
enrollee had an epidural steroid injection on July 7, 2022 and had 100% pain relief. Radiofrequency ablation of 
the lateral sacral branches is considered experimental/investigational because of the wide variation in efficacy 
reported in the literature. Therefore, the enrollee does not meet criteria for the requested 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 radiofrequency ablation to the SI joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on July 5, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you are disputing the share cost. 
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 $50 
copayment for urgently needed services.  
 
You have been asked to pay $50 copayment for urgent care visit. This item/service falls within the urgently 
needed 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 urgent care visit provided 
on July 5, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the excision services coded 11422 provided on September 14, 2021. 
 
You asked the Plan to pay for the excision services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that this service does not meet coverage 
requirements. 
 
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. In this case, the Plan has not provided a specific denial reason as to why this 
code is not eligible for payment. No applicable Medicare coverage document has been cited to specify why 
coverage cannot be made for this code.  Therefore, we decided that the Plan has to pay for the excision services 
coded 11422 provided on September 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DCISionRT protein expression profiling (0295U) provided 
on March 15, 2022. 
 
You asked the Plan to pay for DCISionRT protein expression profiling. You say that this testing is medically 
necessary and is not considered experimental. The Plan denied your request. The Plan says this test is 
considered experimental/investigational and is therefore not 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 DCISionRT protein expression profiling. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the limited documentation provided includes only lab results. No 
provider records or progress notes have been submitted for review. There is insufficient evidence to support 
that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the 
enrollees condition(s). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DCISionRT protein expression profiling have not been met. Therefore, we 
decided that the Plan does not have to pay for DCISionRT protein expression profiling (0295U) provided on 
March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Victoza injection 18 mg/3ml. 
 
You asked the Plan to pre-approve an injection. You say that the requested injection is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested drug is on the self-administered drug 
list and is excluded from coverage under Part B. The enrollee does not have pharmacy (drug) benefits 
administered by the Plan. 
 
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 pre-approve a Victoza injection 18 
mg/3ml.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right cochlear Osia implant system. 
 
You asked the Plan to pre-approve a right cochlear Osia implant system. You say that the records provided 
support the need for the requested services. The Plan denied your request. The Plan says you do not have a 
diagnosis of bilateral moderate-to-profound sensorineural hearing impairment. 
 The Plan follows Medicare rules. Medicare rules say that cochlear implantation is only covered for certain 
indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a right cochlear Osia implant system. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record 
indicates that the enrollee has chronic sinusitis resulting in mild hearing loss in the right ear and mild to 
moderate in the left ear.  The record does not indicate that the enrollee has moderate-to-profound sensorineural 
hearing impairment with limited benefit from amplification as defined in the rules. 
 
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 right cochlear Osia implant system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a right cochlear Osia implant system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested testing is medically necessary. 
The Plan denied your request. The Plan says the requested Tempus XG Hereditary Cancer Germline testing is 
not FDA approved. Therefore, the molecular pathology testing is not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the requested genetic test is not FDA 
approved. The NCD confirms that the laboratory testing for Germline Inherited Cancer, using NGS, must have 
FDA approval or clearance, therefore, the test is not covered. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81479).
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 documentation supports that criterion for 
admission to an IRF have been met. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for admission to an IRF. 
 
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 septic olecranon bursitis and cellulitis. 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 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgical support provided on August 11, 
2022. 
 
You asked the Plan to waive the coinsurance for surgical support. You say that you are disputing the share cost. 
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 20% 
coinsurance for prosthetic devices and related supplies. The allowed amount of this surgical support total 
$284.92, resulting in a coinsurance amount of $56.98. 
 
You have been asked to pay 20% coinsurance for surgical support. This item/service falls within the prosthetic 
devices and related 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 coinsurance for surgical 
support provided on August 11, 2022.