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

 
We decided that the Plan does not have to pay for a mental health visit provided on May 18, 2022. 
 
You asked the Plan to pay for a mental health visit. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a mental health visit provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve access to special supplemental benefit for the 
chronically ill (SSBCI). 
 
You asked the Plan to pre-approve access to SSBCI. You say that you are a appealing the denial for access to 
SSBI benefits. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
expanded benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not have one of the eligible 
conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-
approve access to special supplemental benefit for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the requested drug is medically necessary for 
treatment of the enrollee's acute myeloblastic leukemia. The Plan denied your request. The Plan says use of the 
requested drug is off-label and not medically accepted. 
 
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 Udenyca. Our reviewer says that the 
criteria for coverage of Udenyca have not been met. Our physician reviewer found Udenyca is not FDA-
approved for the enrollee's diagnosis. The use of Udenyca is not supported by one of the major drug compendia 
or by clinical research that appears in a Medicare-approved medical journal. The documentation does not 
support that Udenyca 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29879 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 29879. You say that the documentation supports medical 
necessity. 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 29879 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 the 
procedure code have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
29879 billed for date of service August 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary for the enrollee to return to her 
previous activities. The Plan denied your request. The Plan says the requested IRF admission 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an IRF stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture. The enrollees 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 enrollee may have 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 patient 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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic testing to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve diagnostic tests. You say that this testing is for a necessary procedure. The 
Plan denied your request. The Plan says this provider is out-of-network with the Plan and these tests can be 
performed within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
diagnostic testing to be provided by an out-of-network (OON) provider.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
medical necessity criteria for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is improving but still requires acute care services and these have not 
been denied. The medical record does not indicate the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the dialysis services provided from February 1, 2022, to February 28, 
2022. 
 
You asked the Plan to pay for the dialysis services. You say that these services should be covered by your 
insurance. The Plan denied your request. The Plan says that the services are not covered. 
 
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. Specifically, the provided documentation does not indicate why the services 
were denied. Without a denial reason, we cannot determine whether or not that decision was correct. Therefore, 
we decided that the Plan has to pay for the dialysis services provided from February 1, 2022, to February 28, 
2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Unna boot strapping provided from March 
24, 2022, to April 11, 2022.  
 
You asked the Plan to waive the copayments for boot strapping. You say that you were unaware of the cost of 
the procedures. 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 a $350 
copayment for in-network Medicare-covered surgery or other services at an outpatient hospital.  
 
You have been asked to pay $173.96, which is less than a $350 copayment for each boot strapping procedure. 
You have been asked to pay a total of $695.84 ($173.96 copayment x 4 procedures = $695.84). This 
item/service falls within the outpatient surgery 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 Unna boot strapping provided from March 24, 2022, to April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hip replacement surgery performed by 
an in-network provider on July 12, 2022, and the specialist visit provided by an in-network provider on October 
20, 2022. 
 
You asked the Plan to waive the copayment for the surgery and the specialist visit. You say that you were told 
that you didn't have to pay for these services. 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 a $285 
copayment for each in and out-of-network Medicare-covered visit to an outpatient hospital facility for 
outpatient surgery services, and a $35 copayment for each in-network Medicare-covered specialist visit. You have been asked to pay a $35 copayment for the surgery because the Plan is only holding you responsible 
for this amount, which is less than $285. This item/service falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. You have 
also been asked to pay a $35 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctors 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 the hip replacement surgery performed by an in-network provider on July 12, 2022, 
and the specialist visit provided by an in-network provider on October 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on May 
18, 2022. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that you were not able to get to your 
appointment any other way because you are in a wheelchair. You also say that at the time of the appointment, 
you were not allowed to bear any weight on your right leg, and you needed assistance from two people to get in 
and out of the wheelchair. The Plan denied your request. The Plan says there is no provider order for a 
wheelchair van, and no medical records were submitted despite multiple requests. The Plan also says there is 
no documentation supporting evidence of a medical emergency. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulation supplies provided on August 27, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the services are considered experimental or investigational. 
 
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. 
 
We looked at the file and the rules. Electrical stimulation is a Medicare covered service. When the device is 
covered, the related accessories are covered. The Plan has not provided documentation or Medicare ruling to 
show that the services were experimental or investigational for this case. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the electrical stimulation supplies provided on August 27, 
2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthrodesis of the sacroiliac joint (27279). 
 
You asked the Plan to pre-approve an arthrodesis of the sacroiliac joint. The Plan denied your request. The Plan 
says this request is not medically necessary because you did not have 75% less pain from the previous 
injections you received. 
 
The Plan follows Medicare rules. Medicare rules say that minimally-invasive surgical (MIS) fusion of the 
sacroiliac joint (SIJ) is considered medically necessary when all of the criteria listed in the Medicare rules 
section of this letter 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 an arthrodesis of the sacroiliac joint. 
Our reviewer says that you do not meet the criteria for coverage for an arthrodesis of the sacroiliac joint. Our 
physician reviewer found that you are noted to have tried and failed rest, medications, ice/heat, massage, 
physical therapy, chiropractic care, as well as sacroiliac joint injections, but are not clearly documented to have 
tried bracing and a home exercise program. Our reviewer found that the diagnostic testing provided did not 
corroborate sacroiliac joint pathology. It also did not rule out hip pathology or lumbar spine conditions that 
could contribute to the pain. Our physician reviewer found that you are noted to have had two sacroiliac joint 
injections on the right; however, the injections were noted to have provided roughly 60-70% temporary relief. 
The documentation also did not corroborate that there was ability to perform previously painful maneuvers. 
Our reviewer also found that you do not meet all of the indications for coverage. 
 
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 arthrodesis of the sacroiliac joint have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an arthrodesis of the sacroiliac joint (27279).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 27, 
2022, to July 1, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee's knee pain was 
managed by opioids under a doctor's care. You also say that the enrollee suffered from a declining mental 
capacity, and was admitted for an inpatient hospital stay for detoxification. The Plan denied your request. The 
Plan says none of the supplied documentation meets medical necessity criteria for inpatient opioid 
detoxification. The Plan also says that outpatient or partial inpatient substance abuse program could have been 
considered. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the provided documentation did not suggest the enrollee needed inpatient 
detox, and would have been appropriate for an outpatient or partial inpatient program. Our reviewer also found 
that there was no indication from the provided notes that the enrollee might have required inpatient services 
that would have likely crossed 2 midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from June 27, 2022, to July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88304 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for procedure code 88304. The Plan denied your request. The Plan says the 
professional interpretation must be billed with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code 88304. This means there is both a 
professional and technical component for the code. In this case, an appropriate modifier to indicate the 
professional component has not been billed with code 88304. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88304 billed for date of service October 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 8, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on September 8, 2022.