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 you believe that this level of care is necessary for 
your recovery. The Plan denied your request. The Plan says the criteria for IRF care have not been met. 
 
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 enrollee was admitted to the hospital on 9/9/2022, with weakness and 
encephalopathy.  He was treated in the hospital with intravenous fluids and insulin for diabetic ketoacidosis and acute kidney 
injury and his condition has stabilized. He is weak and deconditioned and is working with physical and 
occupational therapy. He is walking 25 feet with a wheeled walker with contact guard assistance and is contact 
guard assist for transfers and moderate assist for some activities of daily living (lower body dressing).  
 
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 patients medical conditions appear 
stable on outpatient medications with no issues that appear to require a physicians evaluation three or more 
times per week. Provided medical records do not explain why the intensive inpatient rehabilitation therapy 
program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for the patient. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the skin debridement procedure you had at 
an outpatient hospital clinic on May 20, 2022. 
 
You asked the Plan to reduce the copayment for the skin debridement procedure. You say that you believe the 
copayment for a specialist should only be $25.  You said that you are on a fixed income and would not have 
gone to the doctor had you known the copayment would be $200. The Plan denied your request. The Plan says 
you were charged this copayment 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 $200 
copayment for outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $200 copayment for the skin debridement procedure. You had this skin 
debridement procedure at an outpatient hospital clinic, not in a specialist's office.  Skin debridement is 
considered a surgical procedure.  That is why the skin debridement procedure falls within the outpatient 
surgery in an outpatient hospital facility 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 reduce the copayment 
for the skin debridement procedure you had at an outpatient hospital clinic on May 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal decompression and kyphoplasty. 
 
You asked the Plan to pre-approve the requested spinal surgery. You say that you feel this surgery is medically 
necessary. The Plan denied your request. The Plan says there is not sufficient documentation to support this 
request. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested spinal surgery. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has metastatic cancer to the spine. There is description of extensive 
spine metastases. Not enough clinical information has been presented to justify spinal surgery and kyphoplasty 
at this time. 
 
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 surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal decompression and kyphoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses you purchased on February 20, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you did not use your full $300 eyeglass benefit 
when you purchased glasses in 2021, so the leftover amount should be applied to these eyeglasses. The Plan denied your request. The Plan says you had already received coverage for eyeglasses on April 1, 2021, so you 
were not eligible for eyeglasses on the date of service in this appeal. 
 
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 one pair of standard lenses and frames every two years. You have a $300 allowance 
towards these eyeglasses. You already received a pair of covered eyeglasses in 2021.  You are only entitled to 
coverage of one pair of eyeglasses every two years.  That does not mean that if you do not exhaust the $300 
allowance with that first pair that you can apply the balance to a second pair.  This benefit is limited to one pair 
of glasses every two years, regardless of whether or not you spend less than the allowance on them. Based on 
this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, 
we decided that the Plan does not have to pay for eyeglasses you purchased on February 20, 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. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says criteria for this level of care have not been met. 
 
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 enrollee is a 77-year-old female with a past medical history of arthritis who 
underwent an uncomplicated robotic sigmoidectomy and rectopexy on 09/12/2022 for a chronic rectal prolapse. She has been an inpatient in the hospital since surgery and has been treated for post-operative hyponatremia, 
hypertension and dizziness all of which appear improved. She is weak and deconditioned and is working with 
physical and occupational therapy in the hospital.  
 
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 patients medical conditions appear 
stable on outpatient medications with no issues that appear to require a physicians evaluation three or more 
times per week. Provided medical records do not explain why the intensive inpatient rehabilitation therapy 
program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not 
appropriate for the patient. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on April 5, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 physician services provided to the enrollee on 
April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on April 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient visit provided on April 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound image-guided radiotherapy (IGRT) 
techniques. 
 
You asked the Plan to pre-approve the IGRT planning. You say that it is felt that the requested radiation 
treatment is medically necessary. The Plan denied your request. The Plan says the requested service is not 
considered medically necessary in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the IGRT planning. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the treatment using electronic brachytherapy is not at issue in this case, but that the 
issue is the need for image-guided radiotherapy (IGRT). IGRT is a means to improve set-up accuracy. IGRT 
uses daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, 
IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be 
reduced, and thus allow reduction in the volume of normal tissues exposed to radiation.   
 Usually, IGRT is used when critical structures are abutting or in close proximity to the target that is being 
treated to high doses. This situation does not apply to this patient for which the target lesion can be seen on the 
skin to assist in daily set up. While the use of ultrasound daily during radiation therapy is not unreasonable, it is 
found that payment for these simple daily simulations is not supported as the clinical need for this is not 
established by published data or supported by consensus guidelines. This is not considered medically necessary 
as it is not to be furnished in accordance with accepted standards of medical practice. 
 
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 IGRT planning have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasound image-guided radiotherapy (IGRT) techniques.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that this should be covered because you were 
under the impression that there was no copay for follow up after surgery. The Plan denied your request. The 
Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $10 copayment for Medicare-covered x-rays.  
 
 
 
 
 
 
 
 The enrollee has been asked to pay a $10 copayment for an x-ray. An x-ray falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for an x-ray provided on April 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
January 3, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you disagree with the 
copayment applied for the emergency room visit. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $70 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
May 20, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided to the 
enrollee on May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (darbepoetin alfa) injections. 
 
You asked the Plan to pre-approve the Aranesp treatments. You say that it is felt that this is a necessary 
treatment. The Plan denied your request. The Plan says this use of Aranesp is not supported in the literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the Aranesp treatments. Our reviewer 
says that the requested treatment is not considered medically reasonable and necessary. Our physician reviewer 
found Anemia due to scleroderma is not a covered indication for Aranesp. The review has determined that the 
requested use of Aranesp is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
 
 
 
 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 Aranesp treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Aranesp (darbepoetin alfa) injections.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that admission to SNF is medically necessary. The Plan 
denied your request. The Plan says daily skilled services are not needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is an 82-year-old male with a past medical history of hypertension, heart 
failure and lung disease who presented to the acute hospital on 09/04/2022 with syncope. He was treated in the 
hospital with intravenous antibiotics for urosepsis with encephalopathy and his condition has stabilized. He is 
weak and deconditioned and is working with physical and occupational therapy.  
 
The records do not show that the enrollee requires the specialized skill, knowledge and judgment of a skilled 
professional nurse are not required to safely and effectively provide medically necessary and reasonable 
treatment. Records do not document the need for intravenous medications, new tube feeding, or ostomy care or 
daily complex wound care or respiratory care. While skilled therapy is needed, provided records do not 
document a significant decline in the patients functional status compared to his recent baseline to necessitate 
daily inpatient skilled therapy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aortography, angiography, and radiological supervision 
(procedure codes 75625 and 75710) provided to the enrollee on February 25, 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 denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 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 the the aortagram and the 
unilateral lower extremity angiogram both before and after the procedure would ordinarily be part of CPT 
37228. 
 
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 aortography, angiography, and radiological supervision (procedure codes 75625 and 75710) 
provided to the enrollee on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pneumatic compression device you 
received on May 31, 2022. 
 
You asked the Plan to waive the coinsurance for the pneumatic compression device. You say that the provider 
told you that you would not have to pay anything.  You said that you cannot afford this coinsurance. The Plan 
denied your request. The Plan says you were charged this coinsurance 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 10% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 10% coinsurance for the pneumatic compression device. The pneumatic 
compression device falls within the durable medical equipment benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the pneumatic compression device you received on May 31, 2022.   
Your complaint about the provider telling you that you would not have to pay anything is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.