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

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64484, 64483). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections may be medically necessary when 
the first injection directly and significantly provided improvement of the condition being treated and the 
medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using same scale for at least three months. 
 
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 epidural steroid injections. Our 
reviewer says that repeat injections are not medically necessary. Our physician reviewer found the record 
shows the initial injection only provided pain relief for 3 to 4 weeks. Medicare rules require at least three 
months of relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (64484, 64483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hot tub/whirlpool. 
 
You asked the Plan to pre-approve the tub. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered by Medicare. 
 
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 tub. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the enrollee is homebound. The 
provided records do not document a medical necessity for or describe a therapeutic benefit of the 
requested portable whirlpool. 
 
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 tub have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a hot tub/whirlpool.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for hospital observation care 
provided on October 21, 2021. 
 
You asked the Plan to waive the deductible and copayment for the hospital observation care. You say that you 
feel you were misinformed about the overnight stay. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible and the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a $125 copayment for outpatient hospital 
observation services after the deductible is met.  
The item or service you asked the Plan to waive the deductible and copayment for falls within the Outpatient 
Hospital Observation benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is $750 deductible which applies to certain items and services. This cost sharing is a 
contractual obligation that had not been met at the time the hospital observation care was received on October 
21, 2021. The file shows that the $750 was applied to your deductible. Once this was met, you are responsible 
for a $125 copayment for the remainder of the charges. Therefore, we decided that the Plan does not have to 
waive the deductible and copayment for hospital observation care provided on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Omnipod insulin pack. 
 
You asked the Plan to pre-approve the Omnipod insulin packs. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is a disposable insulin system which is not covered by Medicare 
Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. 
 
Although this may be appropriate, neither Medicare nor the Plan offers coverage for this under the medical 
benefit. Therefore, we decided that the Plan does not have to pre-approve the Omnipod insulin pack.  
 
Benefits for the Omnipod insulin packs 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: 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted after a motor vehicle accident for subarachnoid hemorrhage, pelvic fractures, rib fracture, radial 
fracture, right malleolus fracture, and manubrial fracture. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth outpatient mental health visit 
(99213) rendered on October 27, 2021. 
 
You asked the Plan to waive the copayment for a telehealth outpatient mental health visit. You say that you 
received a bill for $30 copayment from the provider and you were not notified that after September 2021 you 
would be responsible for the copayments for the virtual doctor visits. You also say you do not feel you should 
be responsible for this copayment. The Plan denied your request. The Plan says you were charged the correct 
copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for each telehealth outpatient mental health or outpatient psychiatric individual therapy visit.  
 
You have been asked to pay a $30 copayment for a telehealth outpatient mental health visit. A telehealth 
outpatient mental health visit falls within the outpatient mental health 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 a telehealth outpatient mental health visit 
(99213) rendered on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit (99334) and debridement of nails (11721) 
provided on October 6, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a physician visit and debridement of nails. You say that the services at issue were 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-
network care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a physician visit (99334) and debridement of nails 
(11721) provided on October 6, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen and 
pelvis for the enrollee. 
 
You asked the Plan to pre-approve the scan. 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. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the recent physical 
exam revealed normal bowel sounds, no abdominal tenderness and a soft abdomen. No leukocytosis has been 
documented. The enrollee has been passing flatus, and has had normal bowel movements. A differential 
including small bowel obstruction was offered but the impression doubted obstruction. The enrollee has had a 
normal esophagogastroduodenoscopy (EGD) and colonoscopy recently. There are no plain x-rays of the 
abdomen done to evaluate for any findings suspicious for small bowel obstruction (SBO). Absent any further 
clinical history, the medical necessity of CT of the abdomen and pelvis has not been established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for. 
chest pain and shortness of breath. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on November 1, 
2021, by an out-of-network provider. 
 
You asked the Plan to pay for an X-ray of the chest. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have 
not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an X-ray of the chest (71045) provided on 
November 1, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Inpatient hospital stay from July 23, 
2021 to July 29, 2021 
 
You asked the Plan to waive the copayment for Inpatient hospital stay. You say that you do not have money for 
this. The Plan denied your request. The Plan says the copayment you are being charged 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 $320 
copayment per day for days 1-5 for Inpatient hospital stay. Due to the $1,600 out-of-pocket limit for each stay, 
the total cost share is $1,600. 
 
You have been asked to pay a $320 copayment per day for days 1-5 for an Inpatient hospital stay. An Inpatient 
hospital stay falls within the Inpatient hospital 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 Inpatient hospital stay from 
July 23, 2021 to July 29, 2021.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical management of a tibial fracture. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Interferon Alfa-2B (J9214). 
 
You asked the Plan to pre-approve Interferon Alfa-2B. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says this drug is not indicated for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Interferon Alfa-2B. Our reviewer says 
that this drug is not medically necessary in this case. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of  conjunctival intraepithelial neoplasia (CIN). The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Interferon Alfa-2B have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Interferon Alfa-2B (J9214).
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.