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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 you were admitted for sepsis. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While 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. In conclusion, 
there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on 
January 12, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you had not been charged for the 
injections previously. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $366.30, which is 20% of the allowed amount for the injection ($1,831.50 allowed 
amount x 20% coinsurance = $366.30). The injection falls within the Medicare Part B Prescription Drugs 
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 an aflibercept injection 
provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the sacroiliac joint. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 radiofrequency ablation to the 
sacroiliac joint. 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 
approach because of the wide variation in efficacy reported in the peer reviewed literature.  Therefore, the 
request is considered not medically reasonable or 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 radiofrequency ablation to the sacroiliac joint have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for the surgery services provided on February 
14, 2022. 
 
You asked the Plan to lower the copayment for the surgery services. You say that you had this procedure done 
before and the copayment was lower. The Plan denied your request. The Plan says they confirmed with the 
provider that the correct code was billed, and the enrollee received different injections prior. Therefore, the 
proper copayment was applied. 
 
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 $250 
copayment for each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or 
ambulatory surgical center.  
 
  You have been asked to pay a $250 copayment for the surgery services. The surgery services fall within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 lower the copayment for the surgery services provided on 
February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) provided 
on January 22, 2022. 
 
You asked the Plan to pay for supplies for a continuous glucose monitor. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for supplies for a continuous glucose monitor until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) 
provided on January 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet injection. 
 
You asked the Plan to pre-approve a lumbar/sacral facet injection. 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 follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet specific criteria. 
 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 lumbar/sacral facet injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found this enrollee has 
multiple pain generators (lumbar radiculopathy and spinal stenosis) and therefore, does not conform to the 
LCD criteria. Facet disease is a diagnosis of exclusion and the other pain generators have not been addressed. 
Therefore, the request is deemed not medically reasonable or 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 a lumbar/sacral facet injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lumbar/sacral facet injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment and walker on March 
7, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment and walker. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the cost share 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 a 20% 
coinsurance for oxygen equipment and walker. The total allowed amount of the oxygen equipment is $123.09, 
resulting in a coinsurance amount of $24.62. The total allowed amount of the walker is $74.21, resulting in a 
coinsurance amount of $14.84. The total cost share is $39.46. 
 
 
 
 
 You have been asked to pay a 20% coinsurance for oxygen equipment and walker. Oxygen equipment and 
walker falls within the Durable medical equipment (DME) and related 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 coinsurance for oxygen equipment and walker on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 1, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 1, 2022 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (37184, 37185) provided July 30, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 37184, & 37185 are not supported in the medical record. Specifically, the operative 
report does not describe the procedures billed in full. Based on this information, we decided that Medicare rules 
for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to 
pay for surgical services (37184, 37185) provided July 30, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on October 29, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says that payment cannot be made for this 
testing because there is no evidence the ordering physician ordered this testing. 
 
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. In this case, the Plan has denied payment for the genetic testing saying that there 
is no evidence the physician who ordered the testing is treating the enrollee. However, the Plan has supplied no 
evidence to support this claim. While the record notes that the Plan apparently attempted to call the ordering 
provider to confirm if the testing was ordered, there is no documentation of the results of this call. In addition, 
medical records have been submitted that indicate the ordering provider in this case is treating the enrollee. 
There is no evidence to support the Plans assertion that the testing was not ordered by a physician treating the 
enrollee. Therefore, we decided that the Plan has to pay for the genetic testing services provided on October 29, 
2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services rendered on April 
27, 2021. 
 
You asked the Plan to waive the deductible for these services. You say that it wasnt the enrollees choice to go 
to this lab. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 yearly deductible which applies to your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient laboratory 
services from an out-of-network provider benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 yearly deductible which applies to your covered medical services. 
This cost sharing is a contractual obligation that had not been met at the time these services were received on 
April 27, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory 
services rendered on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing 
provided to the enrollee on December 21, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this denial was appropriate given the clinical scenario. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided, there is no documentation that the urine polymerase chain 
reaction (PCR) panel testing provided to the enrollee on December 21, 2021 at issue in this case meets 
Medicare criteria for medically reasonable and necessary. The provided records do not document why the PCR testing was necessary and why a standard urinalysis, culture and sensitivity was inadequate to diagnosis and aid 
in treatment of the enrollee's 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for urine polymerase chain reaction (PCR) panel testing provided to the enrollee on December 21, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
December 28, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 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 99285 
is a column II code to column I code 99284. 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 the emergency department visit coded 99285 provided on 
December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lipid panel (80061) hemoglobin; glycated (A1c) (83036) 
provided December 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that medical records provided. Please refer 
attached REQ and result. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of lipid panel (80061) hemoglobin; 
glycated (A1c) (83036) provided December 14, 2021. have been met. The Plan had made multiple attempts to 
obtain medical records without success. Therefore, we decided that the Plan does not have to pay for lipid 
panel (80061) hemoglobin; glycated (A1c) (83036) provided December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 5, 2022. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a home visit provided on February 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the approved visits should be enough to complete goals, teach a home exercise program, 
and establish a safe discharge plan. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that in this case, the 
documentation doesnt support that the enrollee requires additional skilled rehab services to provide treatment 
that is medically necessary. The enrollee does not require additional skilled rehab services to effectively 
provide treatment, care, and/or services in order to improve the enrollees condition, perform a maintenance 
program to maintain the members condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home 
health services are not 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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve four home health physical therapy visits for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your baseline. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.