Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic test on February 28, 2022. 
 
You asked the Plan to waive the copayment for diagnostic test. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $50 
copayment for diagnostic test.  
 
You have been asked to pay a $50 copayment for diagnostic test. diagnostic test falls within the Outpatient 
diagnostic tests 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 diagnostic test on February 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on February 
17, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was no longer 
enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99233) provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve caudal epidural steroid injections. 
 
You asked the Plan to pre-approve caudal epidural steroid injections. The Plan denied your request. The Plan 
says caudal epidural steroid injections do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 caudal epidural steroid injections. Our 
reviewer says that caudal epidural steroid injections are not medically necessary. Our physician reviewer found 
that in this case, there is no evidence provided that the member is active in a home exercise program, an active 
rehabilitation program, or a functional restoration program. The review has determined that the requested 
caudal epidural steroid injection does not meet the Medicare LCD coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of caudal epidural steroid injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve caudal epidural steroid injections.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reimburse you for the 8 at-home coronavirus tests purchased from January 18, 
2022, to January 27, 2022. 
 
You asked the Plan to reimburse you for the at-home tests. You say that per the website, you can be reimbursed 
for any coronavirus test kits, up to 8 per month after January 15. The Plan denied your request. The Plan says 
that the at-home tests were purchased prior to when the benefit went into effect. 
 
The Plan must follow Medicare rules. Medicare rules say that plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home tests have been met. Therefore, we decided that the Plan has to reimburse you for the 8 
at-home coronavirus tests purchased from January 18, 2022, to January 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
December 15, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the provision of F1CDx to the enrollee meets 
the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at this the file and Medicare rules. The next generation sequence testing (NGS) testing panel 
performed included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is 
statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene are 
statutorily excluded service. \ Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx (F1CDx) test (0037U) provided December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that the enrollee is expected to get better 
with LTACH care. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
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 need IRF care. The Plan denied your request. 
The Plan says the records do not show the need for the intensity of an IRF or full-time access to a doctor or 
skilled rehabilitation nurse. Your needs can be met at an alternate 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
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: 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 enrollee will require acute care for a 
period of time before being able to discharge to a lower level of care. The Plan denied your request. The Plan 
says the denial of authorization for LTACH care is correct. 
 
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 does not require services at the LTACH that are not available at the 
current acute care hospital. All medically necessary care is being provided in the current 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: 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 enrollee's family elected to admit encompassing 
rehabilitation hospital based on medical guidance. The Plan denied your request. The Plan says the enrollee 
does not meet criteria, is not medically necessary, and a lower level of care might be appropriate. Skilled 
nursing 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 enrollee was admitted to the hospital on July 9, 2022 for low back pain. There are 
no complex nursing or rehabilitation needs. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood smear (85060) provided on November 29, 2021. 
 
You asked the Plan to pay for a blood smear. You say that this is supported in the records. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients. 
 
We looked at the file and Medicare rules. The record indicates that the enrollee was a hospital outpatient at the 
time of service. Based on this information, we decided that Medicare rules for coverage of a blood smear have 
not been met. Therefore, we decided that the Plan does not have to pay for a blood smear (85060) provided on 
November 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 60 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 60 routine transportation trips. You say that you need 
transportation to get to dialysis. The Plan denied your request. The Plan says once your 60 one-way trips have 
been used, no additional trips can be approved. 
 
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 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. 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 an additional 60 routine transportation trips (A0120).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reimburse you for the 6 at home coronavirus tests purchased on January 28, 
2022. 
 
You asked the Plan to reimburse you for the at home coronavirus tests. You say that a plan representative 
advised that you are covered for the at home coronavirus test kits. You say that you were advised to submit 
reimbursement under the wellness benefit. The Plan denied your request. The Plan says that the at home tests 
were purchased prior to when the benefit went into effect. 
 
The Plan must follow Medicare rules. Medicare rules say that plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at home coronavirus tests have been met. Therefore, we decided that the Plan has to reimburse 
you for the 6 at home coronavirus tests purchased on January 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames (V2020) provided on February 16, 2022 
by an out-of-network (OON) provider. 
 You asked the Plan to pay for the eyeglass frames. You say that you would like to be reimbursed for the 
$250.00 allowance you have for eyeglasses. The Plan denied your request. The Plan says the provider that 
performed these services is not in the Plan's network. The Plan also says that while you are a member of the 
Plan, you must use network providers to get your medical care and services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received these services from 
an OON provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglass 
frames have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass frames 
(V2020) provided on February 16, 2022 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an arterial ultrasound performed on 
 March 31, 2022. 
 
You asked the Plan to waive the coinsurance for an arterial ultrasound performed on March 31, 2022. You say 
that you should not be responsible for this coinsurance because this service was not performed. The Plan 
denied your request. The Plan says you must pay a 20% coinsurance for an ultrasound. 
 
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 Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a 20% coinsurance for an arterial ultrasound. An arterial ultrasound falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Records submitted 
support this service was performed. 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 an arterial 
ultrasound performed on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth, completely bony (D7240) 
on tooth #16. 
 
You asked the Plan to pre-approve removal of an impacted tooth. You say that you cannot eat properly, your 
tooth is very painful. You need to have this tooth removed as soon as possible and it cannot be done in a simple 
extraction procedure. The Plan denied your request. The Plan says the requested service is not covered under 
your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
removal of an impacted tooth, completely bony (D7240) on tooth #16.
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 need IRF care. The Plan denied your request. 
The Plan says you do not meet 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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve Repatha SureClick. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this drug is not among those covered under 
the enrollee's medical benefit. 
 
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 Repatha SureClick.  
 
Benefits for Repatha SureClick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aduhelm. 
 
You asked the Plan to pre-approve Aduhelm. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage of this drug have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Aduhelm provided outside of an approved trial 
or study is national non-covered.  
 
We looked at the file and Medicare rules. In this case, the case record does not indicate that the enrollee is 
participating in an approved trial or study. Based on this information, we decided that Medicare rules for 
coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Aduhelm.