Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from April 7, 2021, 
to April 13, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the DRG 
payment is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.01, defined as acute respiratory failure with 
hypoxia. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the services provided. Our physician 
reviewer found that the enrollee presented to the emergency room with fatigue and shortness of breath. The 
exam noted no respiratory distress and no wheezes. There were decreased breath sounds in the right lower lobe. 
As noted above, although the provider documented acute respiratory failure with hypoxia, reasonable support 
within the health record must be present for that diagnosis. The review has determined that the diagnosis at 
issue is not supported in the medical records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from April 7, 2021, to April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visits provided on May 6, 2021, 
to January 20, 2022. 
 
You asked the Plan to waive the copayment for specialist visits. You say that you never have been charged a 
facility charge before and no one can explain the charge to you. The Plan denied your request. The Plan says 
the coinsurance 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 $225 
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility. If your physicians office is located within a hospital, you may incur and be responsible for a hospital 
facility charge in addition to your physician office visit cost sharing. 
 
You have been asked to pay $1025 for specialist visits ($113.98/visit x 9 = $1025). The $113.98, is less than 
the standard copayment amount of $225. The specialist visits fall 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 specialist visits provided on May 
6, 2021, to January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81455) rendered by the out-of-
network (OON) provider on July 25, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (81455) rendered by the out-of-network (OON) provider on  
July 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a need for an intensive rehabilitation program. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
mitral and tricuspid valve repair complicated by postoperative bleeding, anemia, and acute on chronic renal failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 osteoprosis. She has 
not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug 
would be contraindicated or less effective; therefore, Prolia is 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 Prolia.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that you were advised by the 
behavioral health department to go to the emergency room because you could not breathe. The Plan denied 
your request. The Plan says that the inpatient stay was not medically necessary. 
 
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 pre-approve acute inpatient hospital admission. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the review has determined that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED 
and/or observation care) would span two 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 acute inpatient hospital admission have been met. Therefore, we decided that 
the Plan has to pre-approve an acute inpatient hospital admission.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 18, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this is a yearly follow up service 
and you had no choice but to get it done. The Plan denied your request. The Plan says the proper copayment 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment per day for a Medicare-covered ultrasound. The total allowed amount was $96.70 which is less than 
the copayment amount of $100. Therefore, only $96.70 was charged as a copayment. 
 
  You have been asked to pay a $96.70 copayment for the ultrasound. The ultrasound 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 an ultrasound provided on January 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
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 step-therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 you have right knee osteoarthritis 
confirmed with imaging studies. You have not tried and failed the Plan's required drugs, Orthovisc, Synvisc, or 
Synvisc-One. The records do not show that the required drugs would have adverse affects or be less effective; 
therefore, Gelsyn-3 is 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 Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a viscosupplement for the treatment of hip arthritis. 
 
You asked the Plan to pre-approve a viscosupplement for the treatment of hip arthritis. The Plan denied your 
request. The Plan says a viscosupplement for the treatment of hip arthritis is not medically necessary. 
 
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 a viscosupplement for the treatment of 
hip arthritis. Our reviewer says that the requested viscosupplement for the treatment of hip arthritis is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the medical 
literature states that viscosupplementation therapy is medically necessary for the treatment of osteoarthritis in 
the knee. It is considered experimental and investigational for indications such as chondromalacia patellae, 
facet joint arthropathy, following anterior cruciate ligament reconstruction, meniscectomy, or partial or total 
knee arthroplasty; hemophilic arthropathy, muscle stiffness, spastic hemiparesis, osteochondritis dissecans, 
palendromic rheumatism, patellofemoral arthritis, patellofemoral syndrome (patellar knee pain), peripheral 
nerve pain, plantar nerve entrapment syndrome, psoriatic arthritis, or for use in joints other than the knee (e.g., 
ankle, carpo-metacarpal joint, elbow, hip, metatarso-phalangeal joint, shoulder, thumb, and temporomandibular joint) because the effectiveness of viscosupplementation for these indications has not been established. The 
review has determined that the requested  viscosupplement for the treatment of hip osteoarthritis, at issue, is not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a viscosupplement for the treatment of hip arthritis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a viscosupplement for the treatment of hip 
arthritis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 age-related 
osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drugs, an oral 
bisphosphonate and zoledronic acid. The records do not show that the required drugs would be contraindicated 
or less effective; therefore, the Prolia is 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 Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a rheumatology specialist telehealth visit 
provided on January 31, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you were not informed 
ahead of time that a telehealth visit would have the same copayment as an office visit. You also say if you 
would have known that you would have made the appointment in person instead. 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 $45 
copayment for a telehealth visit.  
 
 You have been asked to pay a $45 copayment for a specialist telehealth visit. A specialist telehealth visit 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 a rheumatology specialist telehealth visit provided on January 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency intranasal ablation procedure to treat 
nasal obstruction. 
 
You asked the Plan to pre-approve radiofrequency intranasal ablation. You say that radiofrequency intranasal 
ablation procedure to treat nasal obstruction is medically necessary. The Plan denied your request. The Plan 
says radiofrequency intranasal ablation procedure to treat nasal obstruction is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency intranasal ablation. Our 
reviewer says that the requested radiofrequency intranasal ablation procedure to treat nasal obstruction is not 
considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency 
intranasal ablation is considered an experimental/ investigational approach to this problem. Therefore, the request is considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency intranasal ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency intranasal ablation procedure to treat nasal 
obstruction.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary cancer panel provided to the enrollee on 
November 18, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the proprietary lab is requesting coverage of the comprehensive panel by stacking codes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed 
disease or disease predisposition are not a benefit and are not covered. Similarly, the costs of 
tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly effects the 
management of the patient may not be reimbursed. Additionally, the performance of multiple molecular tests 
regardless of whether the requisition lists the tests as a panel or individually and completed on a single sample 
is a panel of tests and should be billed under a single CPT code to prevent stacking of codes. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a hereditary cancer panel provided to the enrollee on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON office visit services. You say that the enrollee has been diagnosed 
with aggressive lymphoma and needs the start chemotherapy. The Plan denied your request. The Plan says a 
port for chemotherapy can be placed by the network surgeon the enrollee has already been approved to see. 
 
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 office visit services to be provided by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess. 
 
You asked the Plan to pre-approve Linzess. You say that the enrollee needs this drug. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
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 Linzess.  
 Benefits for Linzess may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.