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 on January 31, 2021, 
through February 3, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration 
because the documentation supports the billed DRG. The Plan denied your request. The Plan says the record 
does not support diagnosis code E87.1. 
 
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 DRG 698 with diagnosis code E87.1. 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 inpatient hospital services. Our reviewer says that the 
documentation does not support DRG 698 with diagnosis code E87.1 (hypo-osmolality and hyponatremia) as 
on admission the enrollee no longer had hyponatremia and was stable throughout the hospital stay. Our 
physician reviewer found the enrollee is a 59 year old male who was treated in the hospital with vomiting, 
weakness, shortness of breath, and chest pain. On presentation sodium was 133. Follow-up testing showed 
sodium 135, 138 following initial treatment.  
 
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 on January 31, 2021, through February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 1, 2021. 
 
You asked the Plan to waive the copayments for the urgent care visits. You say that the visits were only for 
COVID-19 tests. 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 $50 
copayment for each urgent care provider visit.  
You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visits falls within the 
Urgently Needed 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 an urgent 
care visit provided on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and chronic care 
management services provided on December 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and chronic care management services. You say 
that at the time of service, the member was residing at the facility and therefore, the rendering provider was not 
responsible to obtain authorization. You also say that the assisted living facility is responsible to obtain prior 
authorization for all of their patients, which should also cover for the medical treatment provided by the 
rendering 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 and chronic care 
management services provided on December 3, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0427) 
provided on November 8, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $265 
copayment for Ambulance services.  
 
 You have been asked to pay a $265 copayment for ambulance transportation services. 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 ambulance transportation services (A0427) provided on November 8, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750 and 90471) provided on 
October 22, 2021. 
 
You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because you 
were told that you could get this vaccine. The Plan denied your request. The Plan says this vaccine is not 
covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750 and 
90471) provided on October 22, 2021.  
 
 
 Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 16, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you do not need a referral based on your contract. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they 
have also determined that these services are not urgent or emergent, nor were they 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 psychotherapy provided on November 16, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires nursing care greater 
than 6 hours per day for further treatment and management of post-operative care. You also say that the 
enrollee has been in the acute care setting for 45 days and is stable for transfer to the LTACH. The Plan denied 
your request. The Plan says the requested services do not meet the requirements for approval. The Plan also 
says the records do not indicate that the enrollee has completed a full course of treatment. The enrollee has 
continued care needs including therapy and oxygen weaning. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the records show the enrollee is improving and tolerating oxygen weaning post-
extubation. The enrollee requires physical therapy and additional oxygen weaning, both of which can be safely 
completed at the current facility until a lower level of care is appropriate.  
 Furthermore, there are no services provided in the LTACH setting that the patient requires that are not already 
available and covered in the current treatment setting. Our physician reviewer concluded that transfer to 
LTACH is not medically necessary and there is no reasonable expectation that a higher level of care would be 
clinically advantageous. Transfer may be considered once treatment has completed. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
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. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 was admitted to the 
hospital on April 29, 2022 with bipolar disorder (current episode depressed), cocaine abuse, and suicidal 
behavior. Based on the submitted records, it is not expected that she will improve in a reasonable period of time 
beyond the dates in question, as she is not showing suicidal or homicidal ideation and has no auditory or visual 
hallucinations. She was complaint with treatment and is not a danger to herself or others. Continued services 
are not reasonably expected to improve her condition or be for the purpose of diagnosis. Continued services are 
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 continued inpatient psychiatric services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0100). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 24 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 77 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0100).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires 3 hours of therapy per day by a 
multidisciplinary team and daily visits by a psychiatrist to monitor active conditions. You say that the clinical 
documentation supports the medical and functional need for rehab. The Plan denied your request. The Plan 
says services can safely be received in other settings. 
 
  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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
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. 
 
The Plan must follow Medicare rules. Medicare rules say that a sleep study 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document any signs 
or symptoms of obstructive sleep apnea (OSA). While the enrollee's cardiac history is well documented, this in itself is not indicative of OSA. There are no formal signs or symptoms of OSA as required by the Medicare 
rules. The services are 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 a sleep study.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fitting and multiple density inserts to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve fitting and multiple density inserts to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
fitting and multiple density inserts 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 Xarelto tablets. 
 
You asked the Plan to pre-approve Xarelto. The Plan denied your request. The Plan says Xarelto is a self-
administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto tablets.  
 
Benefits for Xarelto may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the 
rehabilitation needs can be safely met in an alternate and lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryotherapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are few published studies addressing the use of cryoablation to treat breast cancer. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has breast cancer, and wishes to do cryotherapy instead of surgery. While waiting for the 
results of the trials concerning cryotherapy, breast-conserving surgery must be considered as the treatment of 
choice for patients with early breast cancer. In spite of encouraging results, to date no studies have 
demonstrated that cryoablation is equal to breast-conserving surgery in terms of local control, disease-free 
survival, or overall survival. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cryotherapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the denial of Keytruda is completely inappropriate. 
The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the 
enrollee has a diagnosis of recurrent, locally advanced, or metastatic esophagogastric adenocarcinoma, PD-L1 
expression, and failure of 1 prior line of treatment. 
 
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 Keytruda. Our reviewer says that the 
enrollee does not meet criteria for the requested use of Keytruda. Our physician reviewer found Keytruda is not 
Food & Drug Administration (FDA) approved for the enrollee's condition. The requested use is not supported 
by one of the major drug compendia or by clinical research appearing in a Medicare-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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.