Persius/hicric huggingface dataset:
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 needs the acute care hospital 
to be able to function at a normal level. You also say that this is vital to the enrollee's overall wellbeing. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information they have about the 
enrollee's condition; the enrollee does not meet all the requirements. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where care is currently being received. Our physician reviewer also found that there are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the Plan. Our physician reviewer also found that all medical necessary care is being provided in the 
current acute care 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablet 5mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug 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 Eliquis tablet 5mg for the 
enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for therapy services (97110, 97112, 97530) provided on November 6, 
2020. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says that they are recouping previous payment of 
97110, 97112, 97530. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear argument to support the reason 
they are recouping previous payment for these services, and no citation or evidence was provided to support the 
denial. Therefore, we decided that the Plan has to pay for therapy services (97110, 97112, 97530) provided on 
November 6, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for inpatient hospital care provided on February 
21, 2022. 
 
You asked the Plan to waive the deductible for the inpatient care. You say that you do not know why insurance 
did not pay any part of the claim. 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 $250 deductible for most Part A services, which applies to certain items 
and services.  
 
 
 
 
 
 
 
 
 The inpatient care falls within the Inpatient Hospital Care benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is $250 deductible for most Part A services, which applies 
to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the 
inpatient care was received on February 21, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for inpatient hospital care provided on February 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xtandi. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is intended for patient self-administration. 
 
 
 
 
 
 
 
 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 Xtandi.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee is a current smoker. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for LDCT. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is not asymptomatic and does not have a 
tobacco smoking history of at least 30 pack-years. Therefore, we decided that the Plan does not have to pre-
approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says the CardioMEMS device is considered unproven and is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoe lift (L3334) provided on December 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a shoe lift. You say that the service at issue was a necessity for your care. The 
Plan denied your request. The Plan says rules for payment for OON services 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 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 shoe lift (L3334) provided on December 20, 
2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RFA to the SI joint (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says RFA used for SI joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. The rules say that RFA used for SI joint pain is 
considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed 
radiofrequency. Therefore, we decided that the Plan does not have to pre-approve RFA to the SI joint (CPT 
code 64625).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper eyelid surgery. 
 
You asked the Plan to pre-approve upper eyelid surgery. 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 blepharoplasty may be considered reconstructive 
when performed for certain circumstances. 
 
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 upper eyelid surgery. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the record provided does not 
include photographs. The record does not establish the presence of specific functional impairments. The record 
provided does not document that the elements of the coverage criteria are satisfied. The elements of the 
coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of upper eyelid surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upper eyelid surgery.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services were not urgent or emergent. 
 
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 home health services provided on February 22, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Human Papillomavirus (HPV), high-risk types (87624) provided January 25, 2022 
 
You asked the Plan to pay for the screening services. You say that please reconsider 87624, $220 charge for 
payment with medical records for this date of service attached per denial. The Plan denied your request. The 
Plan says the enrollee does not meet the Medicare criteria for coverage. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Though this is a covered service, the enrollee is not in the covered age range and therefore, does not meet the 
criteria. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic 
acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (87624) provided January 25, 2022
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 a lower level of care would not be 
suitable for the enrollee as he is too medically complex. The Plan denied your request. The Plan says the 
member is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 the member does not appear stable for transfer at this time. Our physician reviewer 
also found that there is no documentation provided indicating medical necessity for admission to a LTACH, 
and the enrollee is receiving appropriate care at the present acute care hospital. 
 
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided by an out-of-network 
provider on February 14, 2022. 
 
You asked the Plan to pay for hearing aids. You say that you like this brand, and you found these hearing aids 
well below the cost of those offered by the Plan. The Plan denied your request. The Plan says hearing aids are 
only covered when they are purchased through the specified vendor network. The provider in this case is not 
part of the Plan's network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received from a provider within the Plans specified routine hearing vendor 
network.  
 
 
 
 
 
 We looked at the file and the Plan's rules. The hearing aids in this case were received from a provider outside 
of the Plans specified network. Based on this information, we decided that the Plan's rules for coverage of 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids 
(V5298) provided by an out-of-network provider on February 14, 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 you are requesting reconsideration stating records 
are attached for review. The Plan denied your request. The Plan says based on Medicare guidelines, the 
inpatient rehabilitation facility you are requesting do not meet the requirements for approval. 
 
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 living at home with complaints of progressive weakness over 4-6 
months. Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have a 
need for physical 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on August 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home physical therapy visits and 2 home health 
skilled nursing visits. 
 
You asked the Plan to pre-approve 7 home physical therapy visits and 2 home health skilled nursing visits. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 7 home physical therapy visits and 2 
home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee does not have documented home health skilled nursing needs. The 
enrollee does not have documented home health physical therapy needs. As such, the requested, ongoing, home 
health services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 home physical therapy visits and 2 home health skilled nursing visits have not 
been met. Therefore, we decided that the Plan does not have to pre-approve 7 home physical therapy visits and 
2 home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) on November 08, 
2021. 
 
You asked the Plan to waive the copayment for electrocardiogram (EKG). You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged 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 $30 
copayment for Medicare-covered non-radiological diagnostic services. Other outpatient diagnostic tests  non-
radiological diagnostic services. Examples include, but are not limited to EKGs, pulmonary function tests, 
home or lab-based sleep studies, and treadmill stress tests. The provider billed in the amount of $45.67 and the 
allowed amount is $14.94. The allowed amount is less than the copayment amount. Therefore, results in the 
total cost-sharing amount of $14.94.  
 You have been asked to pay a $14.94 copayment for electrocardiogram (EKG), which is less than the 
copayment of $30. Electrocardiogram (EKG) falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
electrocardiogram (EKG) on November 08, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
She has not tried and failed the Plan's required drugs, Infed and Venofer. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Injectafer is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.