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 this is medically necessary. The Plan denied your 
request. The Plan says the services the enrollee needs can be provided safely in other settings, example, a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 respiratory failure. 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 CxBladder test provided to the enrollee on August 24, 
2021. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says this code requires a specific diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. Based on this information, we decided that Medicare rules 
for coverage of the test have not been met. Based on this information, we decided that Medicare rules for 
coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder test provided to the enrollee on August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for infusion services and a 
zoledronic acid injection provided on January 18, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the infusion and injection. The Plan denied 
your request. The Plan says the correct copayment and coinsurance 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 $280 
copayment for surgery or services provided at an outpatient hospital. 
 
Service/Drug Allowed Amount Copayment/Coinsurance 
Infusion Services $79.10 $79.10 (less than $280) 
 $198.63 $198.63 (less than $280) 
Zoledronic Acid $172.18 $34.44 (20%) 
Total:  $312.17 You have been asked to pay $312.17 for the infusion and injection. The infusion falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The injection 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 copayment and coinsurance for infusion services and a zoledronic acid injection 
provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on January 21, 2022 by an out-of-
network (OON) provider. 
 
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 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 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 eye exam provided on January 21, 2022 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible and coinsurance for the provision of test strips 
provided on January 14, 2022. 
 
You asked the Plan to reduce the deductible and coinsurance for the test strips. You say that you only paid 10% 
for the supplies in the past. The Plan denied your request. The Plan says the correct deductible and coinsurance 
were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $100 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a 10% coinsurance for durable medical 
equipment (DME), such as INR test strips. 
 
 
 Item Allowed Amount Deductible/Coinsurance 
INR Test Strips $104.57 $100 (deductible) 
 $4.57 (remaining) $0.46 (10%) 
Total:  $100.46 
 
The item or service you asked the Plan to reduce the deductible and coinsurance for falls within the Durable 
Medical Equipment (DME) and Related Supplies benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $100 deductible which applies to certain items and services. This 
cost sharing is a contractual obligation that had not been met at the time the test strips was received on January 
14, 2022. Once the deductible was met, the Plan applied to 10% coinsurance for the remaining $4.57 allowed 
amount, for a total of $0.46. Therefore, we decided that the Plan does not have to reduce the deductible and 
coinsurance for the provision of test strips provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on January 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the nursing home was responsible 
to obtain prior authorization for their patients, which should cover medical treatments by the provider. The Plan 
denied your request. The Plan says this provider is out-of-network with the Plan, and authorization was not 
obtained prior to the services being rendered. 
 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 a domiciliary or rest home visit provided on 
January 24, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 12, 
2021. 
 
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 denied procedure is considered inclusive to CPT 24341. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 24341 is "Neuroplasty, major peripheral nerve, arm or 
leg, open; other than specified." 
 
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 serivces at Our 
reviewer found that the operative report describes procedures performed in the same anatomical site. Therefore, 
this procedure would not be covered separately. Modifier 59 would not be supported.  
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 surgical services provided to the enrollee on September 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 1, 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 billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a transthoracic echocardiogram (TTE) with 
doppler provided on January 19, 2022. 
 
You asked the Plan to waive the deductible for the TTE with doppler. You say that this test was always covered 
fully. The Plan denied your request. The Plan says the correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the TTE with doppler was received on 
January 19, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a transthoracic 
echocardiogram (TTE) with doppler provided on January 19, 2022.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the medical records do not support the need for an intensive 
rehabilitation therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. 
 
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.  
 The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical 
repair of a femur fracture after a fall. The enrollees medical problems are stable. There are no complex nursing 
or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 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. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung 
cancer screening. 
 
You asked the Plan to pre-approve an LDCT for lung cancer screening. 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 lung cancer screening with LDCT is covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an LDCT for lung cancer screening. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found per CMS 
guidelines LDCT for lung cancer screenings may occur one time per year in patients qualifying for such an 
exam. This enrollee's most recent LDCT was October 4, 2021 thus she is not eligible for LDCT until October 
4, 2022. If there is clinical reason to do a CT prior to that date a diagnostic CT would need to be ordered.  
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 LDCT for lung cancer screening have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung cancer 
screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the eyewear provided on January 21, 2022. 
 
You asked the Plan to pay additionally for the eyewear. You say that you would like the Plan to reconsider 
your request. The Plan denied your request. The Plan says you are covered for up to $175 every year for routine eyewear. The file shows that you last received eyewear on April 13, 2021, to which the Plan paid 
towards. This was less than one year ago. 
 
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 with a $175 allowance once every rolling calendar year. The file 
shows that you last received eyewear on April 13, 2021, to which the Plan paid towards. This was less than one 
year ago. Therefore, we decided that the Plan does not have to pay additionally for the eyewear provided on 
January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator (L8679, 64555). 
 
You asked the Plan to pre-approve the nerve stimulator. You say that the stimulator is medically necessary. The 
Plan denied your request. The Plan says this type of device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ear or auricular electrical devices (e.g., 
DyAnsys) are also non-covered by Medicare as electrical acupuncture. Any other device that is taped on, 
surgically not implanted next to the nerve, or a device that is subcutaneous is non-covered as well. 
 
We looked at the file and Medicare rules. The requested device is not surgically implanted next to a nerve. 
Based on this information, we decided that Medicare rules for coverage of the nerve stimulator have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a nerve stimulator (L8679, 64555).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve MPI. 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 stress testing without cardiac imaging will be 
considered medically reasonable and necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MPI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee is asymptomatic but has a 
family history of coronary artery disease. There is no indication that the electrocardiogram (ECG) is 
uninterpretable. In summary, there is insufficient documentation to support the medical necessity for the 
requested cardiac stress testing 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 MPI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging (MPI).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. 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 epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
epidural steroid injection on April 6, 2022 provided 25% pain relief for approximately 3 days. The review has 
determined that you do not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. 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. 
 
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 Evenity. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug. There is no documentation provided indicating that the plans required drug would 
likely be less effective and/or likely have adverse effects for the 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the frames and lenses (V2020, V2781, V2784, 
and V2750) provided on February 2, 2022. 
 You asked the Plan to pay additionally for the frames and lenses. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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 up to a $100 benefit. 
 
We looked at the file and the Plan's rules. The Plan has applied your $100 benefit to the retail cost of the 
routine frames and lenses. Additionally, the Plan applied a 20% off discount to the remaining cost. You have 
been asked to pay a total of $533.34 ($766.68 total cost - $100 vision benefit = $666.68. $666.68 remaining 
cost x 20% discount = $133.34. $666.68 remaining cost - $133.34 discount = $533.34 enrollee cost). This 
means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we 
decided that the Plan does not have to pay additionally for the frames and lenses (V2020, V2781, V2784, and 
V2750) provided on February 2, 2022.