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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 patient appears to be improving but is still somewhat unstable likely to require 
only short-term additional acute care services to further stabilize that can safely be administered at the current 
facility for the time being. The patient does not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that the patient requires that are not already available 
and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous at this time.  Transfer to a lower level of care may be considered when the patient is more stable and when treatment is 
completed. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
April 22, 2021, through April 30, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $390 
copay for each day one through five for inpatient hospital care.  
 
 
 
 You have been asked to pay a $390 copay for each day one through five for the inpatient hospital care. the 
inpatient hospital care 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 the inpatient hospital care provided from April 22, 2021, through April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left reverse total shoulder arthroplasty (shoulder 
replacement surgery that reverses the normal ball and socket joint in your shoulder) (23472). 
 
You asked the Plan to pre-approve left reverse total shoulder arthroplasty. You say that the requested procedure 
is medically necessary. You also say you have had the surgery done on your right shoulder and know that it is 
effective. You are in constant pain and cannot move my whole left arm barely at all as a result. Your doctor 
recommended that you have this surgery as it was successful in past on your other shoulder. The Plan denied 
your request. The Plan says the requested procedure does not meet criteria. 
 
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 left reverse total shoulder arthroplasty. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you have tried and failed activity modifications, medications, steroid 
injections, and platelet rich plasma injection. Detailed documentation is not evident regarding any rotator cuff 
pathology. The CT scan of the left shoulder demonstrated the rotator cuff musculature is normal in bulk, 
without disproportionate atrophy. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left reverse total shoulder arthroplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left reverse total shoulder arthroplasty (shoulder 
replacement surgery that reverses the normal ball and socket joint in your shoulder) (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services (procedure code 
99239) provided to the enrollee on June 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code remains not supported. 
 
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, the CPT Code Manual definition of code 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, there was no documentation 
showing the time spent providing the services. This documentation is necessary as CPT 99239 is a time-based 
code. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services 
(procedure code 99239) provided to the enrollee on June 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Qbrexza pad. 
 
You asked the Plan to pre-approve Qbrexza. You say that the requested drug is a medical necessity for you. 
The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Qbrexza 
pad.  
 
Benefits for Qbrexza 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chemotherapy (CPT code(s): J9260 and 96450) to be 
provided by a tertiary care facility. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee is one (1) year post 
bone marrow transplant in April 2021 and asking for continuity of care. The Plan denied your request. The Plan 
says the medical care you require can be provided by a network provider. The Plan states a Plan nurse 
contacted the in-network provider who told her that they can perform the procedure and administer the 
chemotherapy. Please call their office to set up an appointment. The Plan states this is a scheduled twelve (12) 
month administration of chemotherapy after stem cell transplant, which was done at a tertiary center. The Plan 
states the enrollee is now one (1) year out in can transition back to the community oncologist who originally 
saw him and referred them for the transplant. The Plan states their in-network oncologist confirmed that they 
can perform the lumbar puncture and administer the chemotherapy. The Plan states the enrollee should make an 
appointment with the in-network physician. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found it is common for 
patients to transfer care to in-network/community setting if doing well 1 year status post stem cell transplant. 
The patient is doing well and can easily transition care. Continued care in a tertiary care center is not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve chemotherapy (CPT code(s): J9260 and 96450) to be provided by a 
tertiary care facility.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tangential biopsy of skin (11102) provided on July 23, 
2020. 
 
You asked the Plan to pay for the tangential biopsy of skin. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare coding regulations. 
 
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, the CPT Code Manual definition of code 11102 is Tangential biopsy of skin (eg, shave, scoop, 
saucerize, curette); single lesion. 
 We looked at the file and Medicare rules. In this case, the services were provided during the 90-day global 
surgery period. The services performed were billed with the XS modifier which is not among those modifiers 
eligible for payment according to Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of the tangential biopsy of skin have not been met. Therefore, we decided that the Plan does not 
have to pay for the tangential biopsy of skin (11102) provided on July 23, 2020.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting. 
 
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. You were 
admitted with a urinary tract infection and a post-operative seroma at a below knee amputation site. You 
continue to receive acute care services, and these have not been denied. The medical record does not indicate 
that you require services that you are not currently receiving but that would be available at the LTACH facility. 
Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiology specialist office visit with an 
electrocardiogram (EKG) provided on July 15, 2021. 
 
You asked the Plan to waive the copayment for a cardiology specialist office visit with an electrocardiogram 
(EKG). You say that this should be paid. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 a specialist office visit.  
 
You have been asked to pay a total of $30 for a cardiology specialist office visit with an electrocardiogram 
(EKG). The Explanation of Benefits show you were charged $14.26 for the EKG and $15.74 for the office visit ($14.26 
+ $15.74 = $30 copayment). A cardiology specialist office visit with an electrocardiogram (EKG) falls within 
the Physician/Practitioner Services, Including Doctor's 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 a cardiology specialist office visit with an electrocardiogram (EKG) provided on 
July 15, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tinted and photochromatic lenses (V2744), provided on 
July 13, 2021. 
 
You asked the Plan to pay for the tinted and photochromatic lenses. You say that you need this item. The Plan 
denied your request. The Plan says this is not a covered item. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover lens upgrades, including but not limited to: transition, progressive, polish, 
scratch-resistant, or tinted lenses, or insurance. 
 
We looked at the file and the Plan's rules. The plan does not cover lens upgrades, including but not limited to: 
transition, progressive, polish, scratch-resistant, or tinted lenses, or insurance. Based on this information, we 
decided that the Plan's rules for coverage of the tinted and photochromatic lenses have not been met. Therefore, 
we decided that the Plan does not have to pay for the tinted and photochromatic lenses (V2744), provided on 
July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Axolotl Ambient or Axolotl Cryo (Q4215). 
 
You asked the Plan to pre-approve Axolotl Ambient or Cryo. You say that the requested treatment is medically 
necessary. The Plan denied your request. The Plan says the requested treatment is not medically reasonable or 
necessary. 
 
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 Axolotl Ambient. Our reviewer says 
that the requested treatment is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical records provided and the Medicare-approved major drug compendia there is no 
documentation that the requested treatment with Axolotl Ambient or Axolotl Cryo (Q4215) meets Medicare 
criteria for safe, effective, reasonable and necessary in this case. The reviewer found that treatment with human 
amniotic membrane tissue is not proven to be safe, effective, reasonable or necessary for the treatment of 
chronic pain syndrome or myositis as defined by Medicare criteria or the Medicare-approved major drug 
compendia. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Axolotl Ambient have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Axolotl Ambient or Axolotl Cryo (Q4215).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a chest x-ray and a lumbar spine x-ray 
provided on August 7, 2021. 
 
You asked the Plan to waive the copayments for a chest x-ray and a lumbar spine x-ray. You say that you paid 
a $15 copayment at the time of the service, and you were not told by your family doctor that there would be 
three copayments. You also say that you should not have been billed three months after the services took place. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $15 
copayment for each in-network x-ray service.  
 
 You have been asked to pay a $15 copayment for each x-ray, for a total of $30. A chest x-ray and a lumbar 
spine x-ray fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a chest x-ray and a lumbar spine x-ray provided on August 
7, 2021. 
 
Your complaint about being billed three months after services took place is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a stabilizing device to lower a spine level 
(22869). 
 
You asked the Plan to pre-approve placement of a stabilizing device to lower a spine level. You say that the 
requested procedure is medically necessary as your pain is getting worse. You also say you would like 
immediate relief as the shots are painful. The Plan denied your request. The Plan says the requested procedure 
does not meet criteria. 
 
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 placement of a stabilizing device to 
lower a spine level. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ 
investigational procedure. There are no studies that show efficacy and safety. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of stabilizing device to lower spine level have not been met. 
Therefore, we decided that the Plan does not have to pre-approve placement of a stabilizing device to lower a 
spine level (22869).