Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary and will 
provide the enrollee with necessary care to improve their condition and help avoid readmission. The Plan 
denied your request. The Plan says the enrollee's care can be provided at the current facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77012-26-59 billed for date of service 
November 1, 2022. 
 You asked the Plan to pay for procedure code 77012-26-59. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 77012-26-59 is 1. The MAI value for this code is 3. You billed 2 units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 77012-26-59 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 77012-26-59 billed for date of service November 
1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 09, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $125 
copayment for outpatient surgery/Medicare-covered surgical services. 
 
You have been asked to pay a $125 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgical 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 copayment for an outpatient surgery provided on September 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for Piflufolastat f-18 provided on July 13, 
2022. 
 
You asked the Plan to reduce the coinsurance for Piflufolastat f-18. You say that you were expecting to pay 
$95 and cannot afford to pay this amount. The Plan denied your request. The Plan says this cost sharing was 
charged 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 20% 
coinsurance for medical supply. 
 
You have been asked to pay 20% coinsurance for Piflufolastat f-18. This item/service falls within the medical 
supply 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 reduce the coinsurance for Piflufolastat f-18 provided on 
July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (code K0812). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that a power operated vehicle is 
medically necessary. The Plan denied your request. The Plan says a power operated vehicle is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power operated vehicle. Our reviewer 
says that the requested power operated vehicle is not medically necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that you have a personal mobility 
deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, 
grooming and bathing in customary locations within the home. There is no documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. There is no documentation that you 
can safely operate a power mobility device. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle (code K0812).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan does not 
have to pre-approve SSBCI benefits.
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 IRF care 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 that the enrollee did not have a major stroke and had significant improvement from 
the day of admission. The enrollees own performance indicates that he suffered limited neurological damage and does not require intensive rehabilitation 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) services. 
 
You asked the Plan to pre-approve HBOT services. You say that the enrollee cannot take the pain and chronic 
infections are not allowing her to eat. You say that the enrollee's chronic infections have developed in the roots 
of the teeth and the oral surgeon won't pull the teeth out until the enrollee undergoes HBOT. You say that the 
enrollee could develop septicemia and the infection could go everywhere rather than centralized in the 
enrollee's mouth. The Plan denied your request. The Plan says the records do not show that the enrollee has 
existing osteoradionecrosis and that this is being used as an adjunct to conventional therapy. The Plan says that 
the requested HBOT is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBOT will be limited to 
that which is administered in a chamber (including the one-man unit) and is limited to specifically listed 
conditions. Chronic  
 
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 HBOT services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee has osteonecrosis. The 
record sent by her provider indicates that she was evaluated on November 10, 2022, by an oral surgeon for 
extraction of the remaining teeth in her mouth in preparation for dentures. The oral surgeon is requesting to 
perform 20 treatments of hyperbaric oxygen prior to extraction, and 10 dives following the extraction. Records 
from her radiation oncologist dated June 9, 2022, indicate that she completed radiation treatments to her neck 
with local skin reactions. She was evaluated by a hyperbaric medicine specialist on January 9, 2023, and 
physical examination of the mouth was negative for exposed bone. Review of the current literature indicates 
osteoradionecrosis of the jaw is defined as exposed irradiated bone that fails to heal over a period of 3 months 
without evidence of persisting or recurrent tumor. Under Medicare guidelines, the request is not medically 
necessary because the records showed that the enrollee has not had exposed bone in her jaw indicative of 
osteoradionecrosis, and records did not indicate that she had conventional treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing provided on December 10, 2021. 
 
You asked the Plan to pre-approve genetic testing. You say the genetic testing was medically necessary. The 
Plan denied your request. The Plan says the genetic testing 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 genetic testing. Our reviewer says that 
the genetic testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are no provider records to show why this test was warranted. The provider order is for a 
urinalysis and C&S, not a molecular urinary tract infection (UTI) test. While the acquisition of a urine dip, 
urinalysis and/or urine culture and sensitivity (C&S) may have been reasonable, the acquisition of a molecular 
UTI test is not medically necessary or reasonable to diagnosis or treat a UTI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
31, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $50 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $50 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on March 31, 2022, to May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network radiology services 
provided on September 15, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network radiology services. You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged 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 50% 
coinsurance for out-of-network outpatient diagnostic tests/Medicare-covered diagnostic radiology. 
 
You have been asked to pay 50% coinsurance for out-of-network radiology services. This item/service falls 
within the out-of-network outpatient diagnostic tests/Medicare-covered diagnostic radiology 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 out-of-network radiology services provided on September 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits.  
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of SSBCI benefits have been met. Therefore, we decided that the Plan does not 
have to pre-approve SSBCI benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat facet injections 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee received facet joint 
blocks at the L3 to S1 level bilaterally without improvement in pain. Given that there was no pain improvement 
from the previous injections, the criteria for repeat injections are not met. The services are not reasonable or 
medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require an IRF stay with close physician supervision. The Plan denied your request. The Plan says the 
requested 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 that in this case, the complexity of the enrollees nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues to have 
a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, 
the documentation does not support that the enrollee would meet criteria for admission to an acute inpatient 
rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least three 
visits weekly to regain or maintain functional status. The enrollee 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for home infusion therapy provided on 
November 11, 2021, to November 19, 2021. 
 
You asked the Plan to waive the copayment for home infusion therapy. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for home infusion therapy. 
 
You have been asked to pay a $40 copayment for home infusion therapy. This item/service falls within the 
home infusion therapy 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 home 
infusion therapy provided on November 11, 2021, to November 19, 2021.