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

 
We decided that the Plan does not have to pay for the lesion removal rendered on May 23, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that post-surgical management is included in the global 
surgery package. 
 
We looked at the file and Medicare rules. Procedure code 17004 was related to and billed within the 90 day 
global surgical period for major procedure 15240 billed on March 7, 2022. Payment for code 17004 is included 
in the global surgical package. Therefore, we decided that the Plan does not have to pay for the lesion removal 
rendered on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided by an out-of-network provider on 
February 18, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that the service was medically necessary. You say you 
saved the enrollee $900 by pursuing treatment with your practice. The Plan denied your request. The Plan says 
the provider was out-of-network. 
 
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 from in-network vendors.  
 
 We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aid have not been met. Specifically, the provider was out-of-
network. Therefore, we decided that the Plan does not have to pay for the hearing aid provided by an out-of-
network provider on February 18, 2022.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says LTACH admission is not medically necessary as the 
enrollee's condition can be managed at a lower level of care. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that this service was reported correctly. The Plan 
denied your request. The Plan says payment for code 87640 is bundled into payment for code 87641. 
 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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service August 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) computed 
tomography (CT) scan from the skull to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET/CT scan from the skull to mid-thigh. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that initial anti-tumor treatment strategy in Medicare 
beneficiaries who have adenocarcinoma of the prostate is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PET/CT scan from the skull to mid-thigh have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) computed tomography (CT) scan from the 
skull to mid-thigh (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a digital, monaural hearing aid (V5257), assistive 
listening device (V5274) provided on December 23, 2021. 
 
You asked the Plan to pre-approve a digital, monaural hearing aid (V5257), assistive listening device (V5274). 
You say that you called the provider and was told that they accepted your insurance. You also say that after the 
visit they informed you that they do not take your insurance. The Plan denied your request. The Plan says the 
member obtained the hearing aids outside of this Plan supplemental benefit method through their local 
provider. 
 
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 covers the 
hearing aids allowance only when they are purchased from a Plan hearing network provider.  
 
 
  We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of a digital, monaural hearing aid (V5257), assistive listening device (V5274) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a digital, monaural hearing aid 
(V5257), assistive listening device (V5274) provided on December 23, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vyvgart infusions. 
 
You asked the Plan to pre-approve Vyvgart infusions. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have 
not been met. 
 
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 Vyvgart infusions. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the recommended dosage of Vyvgart is 10 mg/kg administered as an intravenous infusion over 
one hour once weekly for 4 weeks. In patients weighing 120 kg or more, the recommended dose of Vyvgart is 
1200 mg (3 vials) per infusion. Administer subsequent treatment cycles based on clinical evaluation. The 
review indicates that the documentation supports that the Vyvgart is medically reasonable and necessary for the 
enrollee. The documentation does support that the Vyvgart 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 Vyvgart infusions have been met. Therefore, we decided that the Plan has to 
pre-approve Vyvgart infusions.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital services provided 
on March 19, 2021, through April 21, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient hospital services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient hospital services have not been met. Specifically, the items and services that have been denied on the Plan's Itemized Bill Summary with code G are considered routine items and services and 
their payment is included in the room and board charge. Additionally, the charge labeled HC Miscellaneous 
Send Out Lab and denied on the Plan's Itemized Bill Summary with code F is not supported by the 
documentation submitted. Therefore, we decided that the Plan does not have to pay an additional amount for 
the inpatient hospital services provided on March 19, 2021, through April 21, 2021.
Appeal type: Hospice
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic radiology services provided on May 7, 2022. 
 
You asked the Plan to pay for the diagnostic radiology services. You say that the enrollee was inpatient at the 
time of the services being provided. The Plan denied your request. The Plan says that the member was enrolled 
in hospice and per CMS guidelines, original Medicare is liable for the claim until the first day of the month 
following the month in which hospice was revoked. 
 
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. The Plan has not provided us with proof of hospice enrollment. Therefore, we 
decided that the Plan has to pay for diagnostic radiology services provided on May 7, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plan's network) will not be 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 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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve surgery. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plan's network) will not be 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 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 
surgery 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 did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says the patient does not meet IRF criteria and can be managed at a 
lower level of care. 
 
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 weakness and a urinary tract infection. Their medical problems are stable, and they have 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 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that you do not actually see patients here, you only process 
the labs. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 lab services provided on October 29, 2021, by an 
out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation provided on June 18, 
2022. 
 
You asked the Plan to waive the copayment for hospital observation. You say that you don't agree 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 hospital observation.  
 
You have been asked to pay a $125 copayment for hospital observation. This item/service falls within the 
outpatient hospital observation 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 
hospital observation provided on June 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Rituxan Hycela. 
 
You asked the Plan to pre-approve Rituxan Hycela. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not 
been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Rituxan Hycela. Our reviewer says that 
the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that 
the Plan requires a trial of drugs Ruxience or Truxima before they will approve the requested drug, Rituxan 
Hycela. There is no indication that the enrollee has tried and failed the required drugs. Based on the medical 
records provided and the Medicare-approved major drug compendia, there is no indication that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects 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 Rituxan Hycela have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Rituxan Hycela.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for van modifications for wheelchair accessibility purchased on 
June 28, 2022. 
 
You asked the Plan to pay for van modifications. You say that you need this in order to travel outside of your 
home. The Plan denied your request. The Plan says items for use outside of your home are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for van modifications for wheelchair accessibility purchased on June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (87532, 87591, 87661) provided on May 4, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service. A panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. 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 genetic testing (87532, 87591, 87661) provided on 
May 4, 2022.