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

 
We decided that the Plan does not have to pre-approve the placement of an implantable loop recorder (ILR.) 
 
You asked the Plan to pre-approve the placement of an ILR. You say that the records provided support the need 
for the requested device. The Plan denied your request. The Plan says the clinical information does not support 
medical necessity. 
 
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 the placement of an ILR. Our reviewer 
says that the placement of an ILR is not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. There is insufficient documentation to support the medical necessity for insertion of an ILR in this 
enrollees clinical management. 
 
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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the placement of an implantable loop recorder (ILR.)
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 records provided support the need for IRF care. 
You say that the intense multidisciplinary team is absolutely essential to identify and establish a base functional 
platform that will drive further recovery, reduce risk of medical and functional regression, and mitigate risk of 
returning to acute hospitalization. You say that you have concern that the enrollee's medical needs will not be 
managed well at a lower level of care. The Plan denied your request. The Plan says the guidelines for coverage 
of IRF care have not been me.t the plan says that the enrollee's needs can be safely met in a less intensive 
setting. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for non-surgical management of cervical fractures after a fall. The enrollee's medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 enrollee 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 the laboratory services (CPT code(s): 82310, 83970, and 
84100) provided on September 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The documentation 
submitted showed that the laboratory tests reported were related to treatment of ESRD since end-stage renal 
disease was indicated as a reason for the laboratory tests, and a separate professional visit unrelated to ESRD 
was not indicated in the medical record.  
 
 Therefore, the laboratory tests are included in the dialysis services. Therefore, we decided that the Plan does 
not have to pay for the laboratory services (CPT code(s): 82310, 83970, and 84100) provided on September 7, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 10, 2021. 
 
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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that immunohistochemical stains are covered when 
specific criteria are met. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the Medicare rules state that most normal 
and abnormal conditions of the esophagus, stomach, duodenum, and colon can be detected by the use of the 
routine H&E stain alone. If special stains or IHC are needed in addition to the routine hematoxylin and eosin 
stain (H&E) stain for gastric specimens, specific documentation to justify the medical necessity for the stain is 
required in the pathology report. There is no specific documentation in the submitted records to justify medical 
necessity of the testing. 
 
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 pay for the laboratory services rendered on December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided from March 
3, 2022, to March 12, 2022. 
 
You asked the Plan to waive the coinsurance for ostomy supplies. You say that you have never been charged 
this much before and you shouldnt now. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for each Medicare covered prosthetic devices and related supplies.  
 
You have been asked to pay $15.30 which is 20% of the allowed amount for ostomy supplies. The allowed 
amount is $76.40 (20% x $76.40=$15.30).  Ostomy supplies fall within the Prosthetic devices 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 the ostomy supplies provided from March 3, 2022, to 
March 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
October 7, 2021, to October 13, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were in the hospital 
due to COVID-19, and this should be covered. The Plan denied your request. The Plan says the copayment 
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 $80 
copayment per day for days 1 through 5 for Medicare-covered inpatient hospital stays. 
 
 You have been asked to pay a total of $400 copayment for the inpatient hospital stay. Inpatient hospital stay 
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 
inpatient hospital stay provided from October 7, 2021, to October 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve consultation services with an out of network (OON) tertiary level 
of care provider at the in-network benefit level. 
 
You asked the Plan to pre-approve the OON consultation services at the in-network benefit level. You say that 
the local oncologist is retiring and that care at the requested tertiary facility is medically necessary. You say 
that the requested OON provider has specific clinical trials for PDL-1 positive tumors such as in this case. The 
Plan denied your request. The Plan says that they have three participating providers that are available in 
network to perform a consultation for the enrollee's cancer. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON consultation services at the in-
network benefit level. Our reviewer says that the criteria for coverage of OON at the in-network benefit level 
have been met. Our physician reviewer found the Plan's denial is not medically justified because they have not 
shown that they can offer clinical trials. The progression of disease of immunotherapy offers limited additional 
options. The Plan has not shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition. A tertiary level of care is medically necessary and the requested OON 
provider can evaluate for clinical trials and other treatment options. National Comprehensive Cancer Network 
(NCCN) guidelines prefer clinical trials over standard therapy when available. 
 
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 OON consultation services at the in-network benefit level have been met. 
Therefore, we decided that the Plan has to pre-approve consultation services with an out of network (OON) 
tertiary level of care provider at the in-network benefit level.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that without the requested injections 
the enrollee's mobility will decrease. You say that the requested injections will help with the enrollee's pain. 
The Plan denied your request. The Plan says that the requested injection services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain 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 facet joint injection services. Our 
reviewer says that the requested injection services are medically reasonable and necessary. Our physician 
reviewer found the enrollee has chronic low back and right hip pain. Imaging has demonstrated a disc bulge, 
spondylolisthesis, and severe multilevel facet arthropathy. The pain persists despite medications, chiropractic 
therapy, physical therapy, and a TENS unit. The documentation supports that the coverage criteria for 
diagnostic facet joint blocks have been met in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection services have been met. Therefore, we decided that the Plan 
has to pre-approve facet joint injection services.  
 
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 pay for drug testing provided on February 10, 2022. 
 
You asked the Plan to pay for drug testing. You say that you weren't aware of the requirement of obtaining a 
prior authorization. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advance. 
 
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 drug testing provided on February 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide/Formoterol Fumarate Dihydrate. 
 
You asked the Plan to pre-approve Budesonide/Formoterol Fumarate Dihydrate. You say that the records 
provided support the need for the requested drug. The Plan denied your request. The Plan says Medicare 
Advantage plans do not cover outpatient prescription drugs. The Plan says that the enrollee may have a 
separate commercial pharmacy benefit or Medicare Part D benefit managed by another carrier. 
 
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 Budesonide/Formoterol 
Fumarate Dihydrate.  
 Benefits for Budesonide/Formoterol Fumarate Dihydrate 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, stance flexion 
feature. 
 
You asked the Plan to pre-approve an endoskeletal knee-shin system, stance flexion feature. 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 a fluid, pneumatic, or electronic/microprocessor knee 
(L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, 
L5840, L5848, L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above. 
 
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 an endoskeletal knee-shin system, 
stance flexion feature. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the health plan has authorized a replacement prosthesis with K3 functional level components. The 
approved prostheses have the requested component already approved therefore an additional approval is 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 an endoskeletal knee-shin system, stance flexion feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, stance 
flexion feature.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on December 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on December 30, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the enrollee does not have pharmacy benefits 
administered under this contract. The Plan says that the enrollee does have Verizon which provides its own 
pharmacy benefits. The Plan says that the enrollee's prescription coverage is provided through Express Scripts. 
 
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 Dupixent.  
 Benefits for Dupixent 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine vision services (92250, 92004, V2020, V2781, 
V2784, and V2744) provided on February 16, 2022. 
 You asked the Plan to pay for the routine vision services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the provider is not an in-network provider 
under your vision benefit. 
 
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 covers these services when provided by an in-network provider. 
 
We looked at the file and the Plan's rules. The provider is not within the Plan's network of vision care 
providers. Based on this information, we decided that the Plan's rules for coverage of the routine vision services 
have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services 
(92250, 92004, V2020, V2781, V2784, and V2744) provided on February 16, 2022.  
 
Your complaint about being initially told the provider accepted your insurance 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on April 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the physician services provided on April 5, 2022, 
by an out-of-network (OON) provider.