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

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for an ECG. You say that this was part of your physical and there 
should be no copayment. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $25 
copayment for in-network non-radiological diagnostic services, including ECGs. The Plan contract also says that an ECG is not considered part of an annual physical exam. 
 
The record shows this claim was approved, and you have a cost sharing amount. According to the EOC, and 
ECG is not considered part of the annual routine physical. You have been asked to pay the allowed amount of 
$11.94, which is less than the $25 copayment for an ECG. An ECG 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 an electrocardiogram (ECG) provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with enhanced electronics 
and a seat lift. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with enhanced electronics and a seat lift. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered when specific criteria 
are met. 
 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 group 3 power wheelchair with 
enhanced electronics and a seat lift. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found there is no clinical documentation to show evidence that you require a group 3 power 
wheelchair with upgraded electronics. A seat elevator is not covered by Medicare. 
 
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 group 3 power wheelchair with enhanced electronics and a seat lift have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
enhanced electronics and a seat lift.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve I-Factor bone graft. 
 
You asked the Plan to pre-approve I-Factor bone graft. 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 I-Factor bone graft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested I-Factor bone graft in 
this case, is 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 I-Factor bone graft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve I-Factor bone graft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmologist visit provided on 
February 1, 2022. 
 
You asked the Plan to waive the copayment for an ophthalmologist visit. You say that there should be no 
copayment for an eye exam. The Plan denied your request. The Plan says it was verified through the medical 
records that the enrollee did not receive a routine eye exam and that it was a diagnostic service, and the 
rendering provider is not a part of the enrollee's supplemental benefit from Davis vision network. Therefore, 
the proper copayment was applied. 
 
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 
copayment for per visit to an ophthalmologist or optometrist for Medicare-covered vision care.  
 You have been asked to pay a $20 copayment for an ophthalmologist visit. An ophthalmologist visit 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. 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 an 
ophthalmologist visit provided on February 1, 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 need IRF care. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary. 
 
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 do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, at an intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is 
no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a 
week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional 
status. You 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from October 15, 2021, to November 8, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $150 
copayment per day for days 21-100 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $600 copayment for 4 days of SNF care ($150 x 4 = $600). 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 skilled nursing facility (SNF) services provided from October 15, 
2021, to November 8, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency services provided to the enrollee on October 10, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billing of code 99285 is not supported by the medical documentation. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation does not support 
level of service billed.  Emergency department visit, must meet or exceed 3 of 3 key components. In this case: 
History - Expanded Focused; Exam - Extensive; MDM - Low Complexity. The documentation more 
appropriately supports CPT 99282. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency services provided to the enrollee on October 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that you cannot be discharged 
without a ventilator for home use. The Plan denied your request. The Plan says a home mechanical ventilator is 
not medically necessary because the needed air pressure can be provided by BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home mechanical ventilator. Our 
reviewer says that a home mechanical ventilator is not medically necessary at this time. Our physician reviewer 
found you have severe chronic obstructive pulmonary disease and have been admitted twice in the last month 
with acute or chronic respiratory failure with CO2 retention. You would likely benefit from BiPAP with 
average volume-assured pressure support (AVAPS) during sleep, as an outpatient. This has not been tried. Medicare does not pay for a home ventilator when used as BiPAP. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86077) provided February 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the number of units billed exceeds the allowed amount.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (86077) 
provided February 8, 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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 are generally medically stable, with no evidence of any complex medical issues 
that require monitoring by an inpatient physician three times per week.  There is no need for acute rehab nursing care. At the current functional level, there is no evidence of need for 
an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. Your needs can be safely addressed at an alternate, low 
intensity level setting such as in a skilled nursing facility, or in-home with 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 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: Favorable

 
We decided that the Plan has to pre-approve Famotidine. 
 
You asked the Plan to pre-approve Famotidine. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this was requested with an incorrect code. 
 
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 Famotidine. Our reviewer says that 
Famotidine is medically necessary in this case. Our physician reviewer found based on the medical records 
provided and the Medicare-approved major drug compendia, there is documentation that Famotidine has been 
requested for a medically accepted indication. However, this medication must be billed with the correct code 
once provided, as code S0028 is not valid for Medicare purposes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Famotidine have been met. Therefore, we decided that the Plan has to pre-
approve Famotidine.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections 
 
You asked the Plan to pre-approve facet joint injections. You say that you have provided medical records to 
support authorization for this service. The Plan denied your request. The Plan says the patient does not meet 
criteria for this service. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are coverable when medically 
necessary and all of the criteria within the Local Coverage Determination are met. 
 
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 facet joint injections. Our reviewer says 
that the patient does not meet criteria for the requested service.  Our physician reviewer found the documentation does not reveal clear details of what prior approved 
procedures the patient has had and the outcomes in terms of objective pain and functional improvement using 
the same scale. The request does not specify a clear level for the requested procedures; therefore, it is not clear 
whether this is a repeat injection at the same anatomic site or evidence of objective outcome from prior 
procedures. There is no documentation of a minimum of consistent 50% improvement in pain for at least six 
(6) months or at least 50% consistent improvement in the ability to perform previously painful movements and 
activities of daily living as compared to baseline measurement using the same scale. Furthermore, the 
guidelines state that for each covered spinal region no more than two (2) radiofrequency sessions will be 
reimbursed per rolling 12 months and the requested procedure exceeds the recommended number of approved 
yearly radiofrequency sessions.  The patient complains of numbness and weakness in her legs and it is also not 
clear whether this is untreated radicular symptoms or non-facet pathology that could explain the patient's pain 
and symptoms including her multiple sclerosis and possibly diabetic polyneuropathy. The patient has a surgical 
history of a "surgical procedure" and it is not clear whether she has had prior lumbar surgery and the guidelines 
do not support facet procedures after an anterior lumbar interbody fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the injection(s), of a diagnostic or 
therapeutic substance(s), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) provided on  
December 10, 2021. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $250 copayment for Medicare-covered surgery or 
other services provided to you at an outpatient hospital, including but not limited to hospital or other facility 
charges and physician or surgical charges.   
 
You have been asked to pay a $250 copayment for the Medicare-covered surgery provided at an outpatient 
hospital. 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 adjust the copayment for the injection(s), of a diagnostic or therapeutic 
substance(s), not including neurolytic substances, including needle or catheter placement, interlaminar epidural 
or subarachnoid, lumbar or sacral; with imaging guidance (62323) provided on December 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is not medically necessary. The Plan denied 
your request. The Plan says this is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.