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

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
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 an ILR 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 enrollee has a history of atrial 
fibrillation but there is no documentation to suggest a history of unexplained syncope, cryptogenic stroke, or 
any other apparent indication for an ILR. The services are therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a shoulder x-ray and an office visit 
provided on June 2, 2022. 
 
You asked the Plan to waive the cost sharing for a shoulder x-ray and an office visit. You say that you cannot 
afford to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for each out-of-network x-ray. Your contract with the Plan also clearly says that you must pay   
40% coinsurance for each out-of-network Medicare-covered visit.  
 
 
 You have been asked to pay $17.40 for a shoulder x-ray ($43.51 x 20% = $17.40). You have been asked to pay 
$61.24 for an office visit ($153.09 x 20% = $61.24). The total you owe is $78.64 ($17.40 + $61.24 = $78.64). 
The x-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. The 
office visit falls within the physician/practitioner services, including doctors office visit 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 cost sharing for a shoulder x-ray and an office visit provided on June 2, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glucagon. 
 
You asked the Plan to pre-approve Glucagon. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not among those covered under the 
enrollee's medical benefit 
 
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 Glucagon.  
 
Benefits for Glucagon 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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services are not reasonable and necessary, and the health plan has no 
contractual obligation to cover services that are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that in this case, the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. There is no documentation of a recent 
injury or decline in function. The additional therapy services are not an appropriate duration and frequency for 
treatment of the enrollees medical condition and therefore are not 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ProAir hydrofluoroalkane (HFA) inhaler. 
 
You asked the Plan to pre-approve ProAir HFA. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered for under the enrollee's medical 
benefit. 
 
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 ProAir hydrofluoroalkane 
(HFA) inhaler.  
 Benefits for ProAir HFA 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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that in this case, the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. There is no documentation of a recent 
injury or decline in function. The additional therapy services are not an appropriate duration and frequency for 
treatment of the enrollees medical condition and therefore are not 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 16, 2021, to 
April 24, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
billed correctly. The Plan denied your request. The Plan says the secondary diagnosis J96.01 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 DRG 480, hip and femur procedures except major 
joint with major complications or comorbidities, and diagnosis J96.01, 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the 
enrollee did not require treatment consistent with acute respiratory failure such as high flow oxygen 
administration, provision of bilevel positive airway pressure (BiPAP), or use of mechanical ventilation.  
 
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 inpatient hospital services provided on April 16, 2021, to April 24, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tezspire (tezepelumab-ekko) treatments. 
 
You asked the Plan to pre-approve the requested use of Tezspire. You say that it is felt that this treatment 
would be beneficial. The Plan denied your request. The Plan says there is no support of the use of this drug for 
the enrollee's condition. 
 
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 requested use of Tezspire. Our 
reviewer says that the requested drug is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of chronic obstructive 
pulmonary disease with severe emphysema. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain 
a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the 
coverage criteria are not satisfied.  
 
 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 use of Tezspire have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Tezspire (tezepelumab-ekko) treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on July 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are requesting reconsideration of payment. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization 
was not obtained. 
 
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 psychotherapy visit provided on July 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint injection services. 
 
You asked the Plan to pre-approve SI joint injection services. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the requested SI joint injections are not medically 
reasonable and 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 SI joint injection services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has been diagnosed with chronic low back pain. In this case, the records 
do not show a physical examination demonstrating tenderness with palpation over the sacroiliac joint or the 
absence of tenderness elsewhere that would explain your symptoms. The records also do not show that there is 
no documentation of any provocative testing done by your provider to indicate if the pain is coming from your 
sacroiliac joint. Therefore, the request is deemed 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 SI joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve sacroiliac (SI) joint injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on April 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services should be 
covered. The Plan denied your request. The Plan says the service is not covered. 
 
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 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 office visit (99214) provided on April 27, 2022, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has no contractual obligation to cover additional physical therapy services that 
are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that in this case, the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program.  There is no documentation of a recent 
injury or further decline in function. The additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollees medical condition and therefore are not 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosela (trilaciclib). 
 
You asked the Plan to pre-approve the Cosela treatments. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested drug, Cosela, is not medically reasonable for enrollee's 
condition. 
 
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 Cosela treatments. Our reviewer 
says that the requested treatment is not reasonable and necessary. Our physician reviewer found the use of this 
drug is not FDA-approved for the enrollee's condition, nor is there support for its use in the Medicare-approved 
compendia. 
 
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 Cosela treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Cosela (trilaciclib).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 27, 
2021, through May 29, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was a medically necessary 
admission. The Plan denied your request. The Plan says the enrollee did not require inpatient care in this case. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was a 72-year-old female with a history of chronic obstructive 
pulmonary disease and atrial fibrillation on Pradaxa. She presented to the hospital due to coughing up blood. 
There was no pulmonary embolism, scarring, or fibrosis. She had Pradaxa held, but no invasive testing was 
necessary as her oxygen levels were normal. The review has determined that the record did not show that at the 
time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 
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 care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 27, 2021, through May 29, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
January 21, 2022, and January 22, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 and N17.9. 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 at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the review has determined that the records did not support the use of secondary diagnosis codes J96.01 
(acute respiratory failure with hypoxia) and N17.9 (acute kidney failure, unspecified) in this case. There were 
no additional evaluation of the patient's renal status noted in the record. There were no additional creatinine 
levels noted in the record.  
 
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 inpatient hospital services provided to the enrollee on January 21, 2022, and January 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on November 18, 2021. 
 
You asked the Plan to pay for the eyewear. You say that you do not feel this was denied correctly. The Plan 
denied your request. The Plan says you did not have cataract surgery. As such, the eyewear is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eyewear, unless it is 
prescribed after a cataract surgery. 
 
The file does not show you have had cataract surgery. Your Plan does not offer a supplemental benefit for this 
eyewear. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on November 18, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on July 25, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that definitive drug testing is indicated when the criteria 
listed in the Medicare rules section of this letter have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of definitive drug testing have not been met. Specifically, the case record does not contain 
documentation of the screening test that necessitated the follow-up definitive drug testing at issue. Therefore, 
we decided that the Plan does not have to pay for definitive drug testing (G0483) provided on July 25, 2022.