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 the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 document does not support medical necessity for admission to an IRF. The member has no medical complexity or rehab nursing needs other than routine nursing care in addition to high 
functional level. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection vedolizumab provided on July 
14, 2022, to September 8, 2022. 
 
You asked the Plan to waive the coinsurance for injection vedolizumab. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amounts of these injections total $17,961.48, 
resulting in a total coinsurance amount of $3,592.30. 
 
You have been asked to pay 20% coinsurance for injection vedolizumab. This item/service 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 
injection vedolizumab provided on July 14, 2022, to September 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional therapy services. You say that the physical therapy helps you 
consecutively. You also say that the range of motion has improved and the pain has been reduced. The Plan 
denied your request. The Plan says the additional therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found per physical therapy notes you have improved range 
of motion, strength, and pain. On review of the available records, you have right shoulder pain but do not meet 
Medicare coverage criteria for the requested additional therapy visits. Additional visits are not medically 
necessary and reasonable based on lack of the physician's documentation and authorization to extend therapy. 
 
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 additional therapy services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested percutaneous vertebral augmentation 
procedure. 
 
You asked the Plan to pre-approve the requested spinal procedure. You say that it is felt that this procedure 
should be approved as the enrollee has confirmed compression fractures causing pain and disability. The Plan 
denied your request. The Plan says this procedure is only covered by Medicare for acute/subacute fractures. 
There is not sufficient documentation to determine the age of the current fracture(s). 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation or kyphoplasty 
may be covered by Medicare for enrollees with either acute (less than 6 weeks) or subacute (less that 12 weeks) 
osteoporotic compression fractures. 
 
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 requested spinal procedure. Our 
reviewer says that the records provided do not support that the Medicare criteria for the requested treatment are 
met. Our physician reviewer found there is no imaging study showing that the fracture is less than 12 weeks 
old. More information would be required to support that criteria have been met. 
 
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 requested spinal procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the requested percutaneous vertebral augmentation procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for urinary bag provided on August 2, 2022. 
 
You asked the Plan to waive the coinsurance for urinary bag. You say that you cannot afford it. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. The allowed amount of urinary bag total 
$451.20, resulting in a total coinsurance amount of $90.24. 
 
You have been asked to pay 20% coinsurance for urinary bag. This item/service falls within the durable 
medical equipment 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 urinary bag provided on August 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is a medical necessity.  The Plan denied 
your request. The Plan says the enrollee does not require an intensive level of therapy requiring physician 
oversight. 
 
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 hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. While the medical record supports a need for physical therapy 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided a in a different level of care. There is not a reasonable expectation that the 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar. 
 
You asked the Plan to pre-approve Vraylar. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says they do not administer pharmacy benefits for the 
enrollee. The Plan says that the medication requested does not fall under Part B coverage. 
 
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 Vraylar.  
 
Benefits for Vraylar 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 copayment for outpatient surgery services provided on 
May 19, 2022, to June 16, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $335 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. There were 5 surgical procedures, resulting in a total copayment amount of 
$1,675. 
 
You have been asked to pay $335 copayment for outpatient surgery services. This item/service 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 copayment for outpatient surgery services 
provided on May 19, 2022, to June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcranial magnetic stimulation (TMS) (90867, 
90868, 90869). 
 
You asked the Plan to pre-approve TMS (90867, 90868, 90869). You say that you are now in full remission 
from your major depressive episode. You also say that you have responded initially to medication changes, but 
your improvement remains very fragile. The Plan denied your request. The Plan says medical necessity criteria 
based on Medicare-Novitas-Local Coverage Determination (L34998), TMS is not met. The Plan also says that 
this was because the provider has not given enough information to show the enrollee needs this service. 
 
 
  The Plan follows Medicare rules. Medicare rules say that the patient must have a confirmed diagnosis of severe 
MDD as defined by the current DSM, the patient has demonstrated a failure of one or more trials of a 
pharmacological medication and/or demonstrates an intolerance to psychopharmacologic medications as 
defined in the definition section above, and the order for the TMS procedure is written by a psychiatrist (MD or 
DO), who has examined the patient face to face and reviewed the record. 
 
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 TMS (90867, 90868, 90869). Our 
reviewer says that based on the information provided, this patient does not meet the clinical criteria for use of 
TMS therapy. Our physician reviewer found the enrollee does not have a documented patient health 
questionaire-9 (PHQ-9) and no documentation of therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS (90867, 90868, 90869) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transcranial magnetic stimulation (TMS) (90867, 90868, 90869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting provided on June 14, 2022. 
 
You asked the Plan to waive the copayment for arthrocentesis, aspiration and/or injection, major joint or bursa 
(eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and 
reporting. You say that you are disputing the share cost. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 
copayment for outpatient hospital services.  
 You have been asked to pay $305.99, which is less than the $350 copayment for arthrocentesis, aspiration 
and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, 
with permanent recording and reporting. This item/service falls within the outpatient hospital services 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 arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting provided on June 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the records support multiple procedures on 
this date of service. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service August 19, 2022.
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 that you are being fed by a feeding tube 
and would get better care at an LTACH. You say that your current living conditions are horrendous, and you 
are being neglected. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and you can safely receive the care in another 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 that you are medically stable on outpatient medications, and are off of mechanical 
ventilation with the tracheostomy capped while also being on room air with a pureed diet. You do not require 
services at an LTACH that are not available in their current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiologic exam provided on July 26, 2022. 
 
You asked the Plan to waive the copayment for radiologic exam. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $55 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $35.61 which is less than the $55 copayment for radiologic exam. This 
item/service falls 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 copayment for radiologic exam provided on July 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quantitative calcium scoring. 
 
You asked the Plan to pre-approve quantitative calcium scoring. You say that quantitative calcium scoring is 
medically necessary. The Plan denied your request. The Plan says Medicare does not cover the requested study 
for screening purposes. 
 
The Plan follows Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service 
and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a screening 
service. When performed in association with CT angiography, there is neither separate nor additional included 
reimbursement for the calcium scoring. 
  
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 quantitative calcium scoring. Our 
reviewer says that quantitative calcium scoring is not medically necessary. Our physician reviewer found that 
in this case, the record indicates that you have hyperlipidemia and have no symptoms suggestive of cardiac 
disease. The rule states that the requested test is never covered for screening, i.e., in the absence of signs, 
symptoms or disease. The requested test is being used for screening and is therefore excluded by Medicares 
rule. The elements of the coverage criteria are not satisfied.   
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of quantitative calcium scoring have not been met. Therefore, we decided that the 
Plan does not have to pre-approve quantitative calcium scoring.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied on the plan's itemized bill 
determination with denial codes G and H provided to the enrollee from February 16, 2022, to March 18, 2022. 
 
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 remaining charges were denied with denial codes G for unbundling and H for administrative 
denial. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of denial code G - the 
services reported separately from the room and board were reviewed and does not meet criteria. The list of 
services were denied correctly, as they would be bundled in the room and board. Non-
Reimbursable/Unbundled Charges include all facility general administrative costs, including routine and/or 
reusable equipment, supplies, and/or items, used multiple times for multiple patients, and/or routine 
items/supplies that are disposable and which Institution must price and include in Institution's overall 
accommodation or facility fees for inpatient room and board, nursery, intensive and non-intensive specialty 
units, emergency room, operating room, recovery room, labor and/or delivery room, anesthesia, radiology, 
laboratory and other charges. These Institution general administrative costs are non-reimbursable if billed 
separately and apart from an inpatient room and board, specialty unit or other overall facility charge. In terms 
of denial code H - for observation care - observation care services would not be reported on the same day as 
room and board services. 
 
We looked at this coder'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 inpatient hospital services denied on the plan's itemized bill determination with denial codes G 
and H provided to the enrollee from February 16, 2022, to March 18, 2022.