Persius/hicric huggingface dataset:
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet requirements for IRF coverage. 
 
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 the intensity of services provided at an IRF. Specifically, you are 
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular 
physician evaluation.  Your care needs can be met at a lower level of care (ex. home with services, long term care, Hospice). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on July 16, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on July 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SNF admission to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that the enrollee is ready 
to start SNF and is aware there are facilities closer but she is requesting to have care at this facility. The Plan 
denied your request. The Plan says the authorization was denied because the request was for a non-contract 
provider. 
 
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 
the SNF admission to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 Prolia. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the review has determined that the 
documentation does support that the Prolia is medically reasonable and necessary for the enrollee. The 
documentation does support that the Prolia is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oncology office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the oncology office visit. You say that you are in pain and your face is 
swollen. You say you need surgery. The Plan denied your request. The Plan says after the out-of-network 
provider's consultation to determine the type of cancer, further care can be provided by a network oncologist. 
 
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 office visit. We found no exception that would require the Plan to pre-approve 
the office visit. The records provided for review do not show that the office visit is urgent or emergent. 
Therefore, we decided that the Plan does not have to pre-approve the oncology office visit to be provided by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you need physical therapy in order to 
regain strength before you are discharged home. You say that you feel you would benefit from an acute facility 
rather than a skilled nursing facility. The Plan denied your request. The Plan says based on Medicare guidelines 
you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that you do not meet the severity of illness or intensity of service criteria for inpatient basis in a SNF. Our 
physician reviewer found that daily skilled services are not necessary. You do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found you do not require daily skilled nursing and/or skilled therapy 
on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 4, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this was a follow up visit 
and you thought that would be covered. 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 $45 
copayment for each specialist visit for Medicare-covered benefits. 
 
You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on March 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure device (LAAC) (33340). 
 
You asked the Plan to pre-approve LAAC. You say that the requested service is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that LAAC is covered when specific criteria are met, such as if 
the enrollee is unable to take oral anticoagulants. 
 
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 LAAC. 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 apparent contraindication to anticoagulation. As such, guidelines would not support 
implantation of a LAAC in this 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 LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve left atrial appendage closure device (LAAC) (33340).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis provided on March 23, 2022. 
 
You asked the Plan to pay for the services provided. You say that the claim met all of the coverage criteria. The 
Plan denied your request. The Plan says there is no mention of the brace in records. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
We looked at the file and the rules. The record does not contain relevant medical records which support 
medical necessity for the supplies provided in this case. The medical records do not show that an ankle orthosis 
was included in the enrollees treatment plan due to weakness or deformity that required stabilization. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the ankle orthosis provided on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiac catheterization to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the cardiac catheterization. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 cardiac catheterization. We found no exception that would require the Plan to 
pre-approve the cardiac catheterization. The records provided for review do not show that the cardiac 
catheterization is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the 
cardiac catheterization to be provided by an out-of-network (OON) provider.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says admission to an IRF 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 the complexity of your nursing, medical, and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehab care.  You do not require treatment by multiple therapies and there is not a reasonable expectation that you will be able to participate in or benefit 
from the intensive treatment program at 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 measurement of post-voiding residual urine and/or bladder 
capacity by ultrasound, non-imaging (51798), urinalysis, by dip stick or tablet reagent for bilirubin, glucose, 
hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these 
constituents; automated, without microscopy (81003), and hospital outpatient clinic visit (G0463) provided on 
April 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for measurement of post-voiding residual urine and/or bladder capacity by 
ultrasound, non-imaging, urinalysis and hospital outpatient clinic visit. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services were provided OON without 
prior authorization. 
 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 measurement of post-voiding residual urine and/or 
bladder capacity by ultrasound, non-imaging (51798), urinalysis, by dip stick or tablet reagent for bilirubin, 
glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of 
these constituents; automated, without microscopy (81003), and hospital outpatient clinic visit (G0463) 
provided on April 7, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 3, 2022. 
 
You asked the Plan to pay for the office visit. You say that the records support the billed services. The Plan 
denied your request. The Plan says the service was not billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The medical records show that the enrollee identifies as a female. We find that CPT code 99214 was billed 
with diagnosis code N401, benign prostatic hyperplasia with lower urinary tract symptoms. Providers should 
use modifier KX to show that it is not an error.  Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device. 
 
You asked the Plan to pre-approve the insertion of stabilization device. You say that the enrollee has suffered 
from this condition for more than five years and has failed 6 months of conservative approaches to treatment. 
You say that recommend this minimally invasive procedure when conservative treatment has failed and as a 
safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says 
there are not enough studies to show the Vertiflex Superion is safe and effective to treat back pain. 
 
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 insertion of stabilization device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the Vertiflex device is experimental and 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 insertion of stabilization device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of stabilization device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency ambulance transportation 
services (A0427 and A0429) provided on February 9, 2022, February 26, 2022, and March 29, 2022. 
 
You asked the Plan to waive the copayments for the emergency ambulance transportation. You say that you 
were quoted a benefit of $200 by customer service for the ambulance benefit, and was not provided an entire 
quote stating that the $200 benefit is one way. You also say you feel that this has now created a hardship as you 
have a large bill. The Plan denied your request. The Plan says you are contractually obligated to the contractual 
copay the amount of $200 for each separate Medicare-covered ambulance service on February 9, 2022, 
February 26, 2022, and March 29, 2022, under the terms of the 2022 Evidence of Coverage. 
 
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 $200 
copayment for Ambulance services.  
 
You have been asked to pay a $200 copayment for the emergency ambulance transportation. The emergency 
ambulance transportation falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the emergency ambulance transportation services (A0427 and A0429) provided on 
February 9, 2022, February 26, 2022, and March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart without 
contrast material with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT of the heart without contrast material with quantitative evaluation of 
coronary calcium.. You say that the requested service is medically necessary. The Plan denied your request. 
The Plan says the service at issue is never covered for screening purposes and 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 a CT of the heart without contrast 
material with quantitative evaluation of coronary calcium. Our reviewer says that the requested service is not 
medically necessary. Our physician reviewer found there is insufficient support in the peer-reviewed literature 
demonstrating a significant benefit of CT imaging of the heart with quantitative evaluation of coronary calcium 
in guiding optimal management of this enrollee. As such, CT imaging of the heart without contrast material 
with quantitative evaluation of coronary calcium is considered experimental/investigational for the evaluation 
and management of this enrollee's medical condition. 
 
   
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 CT of the heart without contrast material with quantitative evaluation of 
coronary calcium. have not been met. Therefore, we decided that the Plan does not have to pre-approve 
computed tomography (CT) of the heart without contrast material with quantitative evaluation of coronary 
calcium (75571).