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

 
We decided that the Plan has to waive the coinsurance for a ferric carboxymaltose injection. 
 
You asked the Plan to waive the coinsurance for a ferric carboxymaltose injection. You say that you cannot 
afford to pay this. The Plan denied your request. The Plan says that the cost share has been applied correctly. 
 
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. Specifically, the Plan has submitted the correct Evidence of Coverage (EOC). 
However, Chapter 4 of the EOC indicates all cost share amounts are listed in the Cost Sharing Guide. The Plan 
failed to submit the Cost Sharing Guide that corresponds to the EOC. This means we are unable to verify the 
amount you are being asked to pay is correct. Therefore, we decided that the Plan has to waive the coinsurance 
for a ferric carboxymaltose injection.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device with associated sleeves 
(E0651, E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device with associated sleeves. You say that the 
enrollee needs the requested items due to lymphedema. The Plan denied your request. The Plan says the 
records received do not indicate that the enrollee has an emergent or urgent medical condition or is in need of 
specialized service(s) that are not available in the network. The enrollee has an HMO plan. There are in-
network providers within a reasonable distance from his location that can provide this service or item. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device with associated sleeves (E0651, E0667) to be provided by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a synvisc injection provided on May 17, 
2022. 
 
You asked the Plan to waive the coinsurance for a synvisc injection. You say that you cannot afford to pay this. 
The Plan denied your request. The Plan says the cost share has been applied 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 drugs that usually aren't self-administered by the patient and are injected or infused while you 
are getting physician, hospital outpatient, or ambulatory surgical center services.  
 
You have been asked to pay $100.19 for a synvisc injection. A synvisc injection 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 a synvisc 
injection provided on May 17, 2022.Your contract with the Plan clearly says that you must pay a 20% coinsurance for out-of-network Medicare Part B prescription drugs. However, you have only been asked to pay 
$100.19, which is less than the 20% coinsurance amount.
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 inpatient rehabilitation to regain the use of 
your leg after a car accident. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 medically stable and do not need a physician's supervision three times a week 
in an IRF. There are no acute rehabilitation nursing needs identified or documented. You do not need intensive 
therapies consisting of at least three hours of therapy per day at least give days per week with multidisciplinary 
approach 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service November 2, 
2021. 
  You asked the Plan to pay for procedure code 72170. You say that procedure code 72170 was not bundled with 
any other procedure code performed on the same date of service. You say that the medical records should be 
reviewed, and the claim processed for payment. The Plan denied your request. The Plan says payment for code 
72170 is bundled into payment for code 73502. 
 
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, we have confirmed that code 72170 
is a column II code to column I code 73502. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72170 billed for date of service November 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hearing aid or assistive listening 
device/supplies/accessories (V5267) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the hearing aid or assistive listening device/supplies/accessories. You say 
that you feel the Plan's coverage should not limit you to the Plan's approved hearing aids. You also say that you 
would like the in-network medical coverage approved for this service. The Plan denied your request. The Plan 
says the provider you have requested to see is OON, and in-network coverage is denied. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use a provider in the Plan's approved hearing network.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid or assistive listening device/supplies/accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a hearing aid or assistive listening 
device/supplies/accessories (V5267) to be rendered by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on November 
28, 2020. 
 
You asked the Plan to pay for the ambulance transportation services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date of 
service.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance transportation services provided on November 
28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 19, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81540 provided on January 21, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the 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. 
 
 
 
 
 
 
 
 
 
  
We find that CPT code 81540 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on January 6, 2022. This means there is no documentation to support the date 
of service billed. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing coded 
81540 provided on January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the appeal is being filed due to your short term needs 
of strengthening and rehabilitation to ensure you can safely return home to live by yourself and perform basic 
activities of daily living. The Plan denied your request. The Plan says based on Medicare guidelines, the 
inpatient rehabilitation facility services you are requesting 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 you were admitted for confusion, diarrhea, and electrolyte abnormalities. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for physical 
or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee needs these injections. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint procedures performed after anterior lumbar 
interbody fusion (ALIF) are considered not reasonable and necessary. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has other clear pathology, post-laminectomy syndrome as well as lumbar 
radiculopathy. Therefore, the reviewer found that the requested injections are 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the required services for the enrollee cannot be 
safely met with home health services or SNF at this time. The Plan denied your request. The Plan says 
admission to IRF was denied as not meeting criteria, is not medically necessary, and a lower level of care might 
appropriate, such as skilled nursing facility (SNF). SNF level of care was offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the enrollee was admitted for a myocardial infection and congestive heart failure. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left lower extremity peripheral angiography with 
possible intervention. 
 
You asked the Plan to pre-approve a left lower extremity peripheral angiography with possible intervention. 
You say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the 
records do not show that the enrollee has met all of the conditions required for coverage of the requested 
treatment. The Plan says that the records do not show that the enrollee is having severe leg pain from poor 
circulation. 
 
The Plan follows Medicare rules. Medicare rules say that PTA and stenting is covered for certain medical 
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 left lower extremity peripheral 
angiography with possible intervention. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found it is documented that the enrollee walks without restrictions, and he has no difficulty 
walking or climbing stairs.  There is documentation that he is asymptomatic for arterial disease.  An arterial 
Doppler study does not provide ankle-brachial indexes (ABIs) but only notes tibial disease bilaterally.  On 
August 8, 2022, the enrollee was documented to have palpable dorsalis pedis pulses bilaterally and it is 
documented that walking makes his legs feel better despite being impacted by his stroke.  Agree with the 
assessment that endovenous ablation of his legs would not be wise, however there is insufficient documentation 
to warrant the medical necessity of arterial intervention. 
 
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 left lower extremity peripheral angiography with possible intervention have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a left lower extremity 
peripheral angiography with possible intervention.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a direct repair of an abdominal aortic aneurysm. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is at risk of rupture if he 
waits for a rupture. The Plan denied your request. The Plan says that the enrollee does not have any symptoms 
that the aneurysm is leaking. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the requested services. Our physician 
reviewer found that the aneurysm was measured at 5.8 cm by the vascular surgeon. The enrollee also has a 
history of back pain. It is untenable to continue to manage the enrollee with back pain (even if the likely source 
of the back pain is spinal in nature) and an aneurysm this large conservatively. Even if the clinical scenario was 
not made more complex by the coexisting back pain, the aneurysm has reached a size where repair is 
warranted. The treatment plan is both reasonable and medically 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a direct repair of an abdominal aortic aneurysm.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that this home modification is necessary. The 
Plan denied your request. The Plan says wheelchair ramps are not covered in accordance with Medicare 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.