Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Meningococcal vaccine (90620) provided July 28, 2021. 
 
You asked the Plan to pay for Meningococcal vaccine. You say that please review the included medical 
documentation that supports medical necessity for the rendered service. The Plan denied your request. The Plan 
says certain preventative immunizations and their administration is not a Medicare covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Meningococcal 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Meningococcal 
vaccine. Therefore, we decided that the Plan does not have to pay for Meningococcal vaccine (90620) provided 
July 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Androgel. 
 
You asked the Plan to pre-approve Androgel. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Androgel.  
 
 
 Benefits for Androgel 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for surgeries provided on March 23, 2021, 
and April 6, 2021. 
 
You asked the Plan to waive the copayments for the surgeries. You say that you thought the procedures were 
fully covered without any copayments. The Plan denied your request. The Plan says the proper copayment was 
applied for both services. 
 
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 $295 
copayment for Medicare-covered surgery. The total copayment amount for both surgeries was $590 ($295 
copayment + $295 copayment). 
 
You have been asked to pay a $590 copayment for the surgeries. The surgeries falls within the Outpatient 
Surgery and Other Medical 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 waive the copayments for surgeries provided on March 
23, 2021, and April 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (97530) provided on August 
18, 2021. 
 
You asked the Plan to pay for occupational therapy. You say that the services 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. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/NPP's service. 
 
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy have not been met. Specifically, the documentation shows that this claim was 
billed by a nurse practitioner but the therapy services at issue were rendered by an Occupational Therapy 
Assistant. A Nurse Practitioner cannot bill for the services of an Occupational Therapy Assistant because a 
Nurse Practitioner does not meet the qualifications of a therapist. Therefore, we decided that the Plan does not 
have to pay for occupational therapy services (97530) provided on August 18, 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 it is your professional opinion that the enrollee will 
receive the appropriate level of care in the acute rehabilitation setting. The Plan denied your request. The Plan 
says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab 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 
doesnt support that she 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 rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis (0242U) provided on 
June 9, 2021. 
 
You asked the Plan to pay for a targeted genomic sequence analysis. You say that the service at issue was a 
necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a targeted genomic sequence analysis have not been met. Specifically, this claim was billed with 
the laboratory place of service code while the records indicate that the enrollees face-to-face service was 
rendered in an office setting. There is a more appropriate place of service code for the services billed. 
Therefore, we decided that the Plan does not have to pay for a targeted genomic sequence analysis (0242U) 
provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 7, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were under the impression that your plan 
would cover the evaluation. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is 
covered every 3 plan years. The Plan also says that the frequency limit has been exceeded. 
 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on August 25, 2020. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic (CT) 
colonography (74261) provided on October 8, 2021. 
 
You asked the Plan to waive the copayment for a CT colonography. You say that these procedures have always 
been paid for by the Plan in the past. The Plan denied your request. The Plan says the correct 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 $115 
copayment for Medicare-covered radiological diagnostic services, not including X-rays or diagnostic 
mammograms.  
 You have been asked to pay $103.43 for a CT colonography. A CT colonography falls within the "Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been 
asked to pay less than or equal to the full and 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 computed tomographic (CT) colonography (74261) 
provided on October 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the drug is not 
approved as first line therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our physician reviewer 
found that the enrollee has non-small cell lung cancer. The requested use of Keytruda is not FDA-approved for 
the enrollee's diagnosis without PDL1 testing. The requested use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not 
indicated, not supported or not recommended in any of the compendia. The documentation does not support 
that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the out of network rates for the pacemaker evaluation and testing (code 
93280) provided on July 28, 2021. 
 
You asked the Plan to waive the out of network rates for the pacemaker evaluation and testing. You say that the 
enrollee was on vacation and needed medical attention. You also say that this was a medical emergency, and 
out of network should not apply. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount. 
 
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 did not submit medical records showing the enrollees condition was 
not, or was no longer, an emergency. Therefore, the Plan cannot cover the service at the out of network rate.  
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). The enrollees contract with the Plan says that the doctors who give 
you emergency care are the ones who decide when you are stable, and the medical emergency is over. The 
contract also says that enrollees must pay a $200 copayment per day, for days 1-5, for in-network inpatient 
hospital care.  
 
The Plan says the enrollee must pay 30% coinsurance for pacemaker evaluation and testing as part of an out of 
network hospital stay. Based on the plan contract, however, the enrollee cannot be asked to pay more than the 
in-network inpatient per day copayment, which includes the cost for the pacemaker evaluation and testing. 
Therefore, the pacemaker evaluation and testing are not subject to a separate out of network coinsurance. We 
decided that the Plan has to waive the out of network rates for the pacemaker evaluation and testing (code 
93280) provided on July 28, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are currently in the hospital and cannot be 
released until you are approved for SNF care. The Plan denied your request. The Plan says the enrollee is at his 
functional baseline and has met all of his goals. The Plan say that the enrollee is not noted to have any daily 
skilled nursing needs. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating 
more than 100 feet and tending to ADLs with modified independence. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, as a practical matter, can be provided 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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 need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee's rehab 
needs can be met safely at a lower intensity and alternate setting such as in 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement ultralight prosthetic socket. 
 
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 a prosthetic socket is 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 the enrollee has a unilateral transtibial 
amputation. The documentation does not reveal any medical reasons for which the enrollee requires ultralight 
materials for this socket. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement ultralight prosthetic socket.
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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications and had stable 
vital signs. You were at a standby assist to contact guard assist level with functional mobility including gait to 
140 feet with a rolling walker. You do not require skilled nursing or therapy services on a daily basis. You do 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider advised you 
that your copayments would only be $10. 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 $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit 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 specialist office visit provided on November 3, 2021.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee's medical needs care being met in the 
current 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. 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 she is currently receiving care. 
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 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 LTACH services.