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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules 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 that the enrollee was admitted for lumbar spinal surgery. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. In conclusion, there is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on February 14, 
2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes the 
FANCC gene, the denial is correct 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication.  
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on February 14, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for home confinement. 
 
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 the additional visits. Our reviewer says 
that the requested visits are not medically reasonable or necessary. Our physician reviewer found that you do 
not have documented ongoing home health physical therapy needs. You are functioning at a level 
commensurate with a lower level of care, such as a home exercise program, outpatient therapy, or layperson 
supervision. As such, the requested ongoing home health physical therapy services are 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 the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic consultation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the orthopedic consultation. You say that you have seen this provider 
before, and you have another appointment with them. The Plan denied your request. The Plan says the 
requested provider is an OON provider and there is an approved authorization for an in-network provider. Also, 
the service requested is 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 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 
an orthopedic consultation to be provided 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 the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment is too 
high, and you cannot afford it. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $350 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $350 for these 
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 the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional blood glucose strips and lancets for twice 
daily use. 
 
You asked the Plan to pre-approve additional blood glucose strips and lancets. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that up to 100 test strips and up to 100 lancets every 3 
months are covered for an enrollee who is not currently being treated with insulin administrations. 
 
 We looked at the file and Medicare rules. Review of the file shows that the enrollee is not being treated with 
insulin administrations. The documentation did not include medical records to support that more supplies are 
medically necessary. Therefore, only up to 100 test strips and lancets are covered every three months. 
Additional supplies per month are not covered. Based on this information, we decided that Medicare rules for 
coverage of additional blood glucose strips and lancets have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional blood glucose strips and lancets for twice daily use.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on March 22, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that the copay is too expensive for the 
diagnostic test, and you were expecting to only have to pay $30 copay for the test. 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 $160 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $445.76 and the allowed amount is $113.19. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $113.19. 
 
 You have been asked to pay a $113.19 copayment, which is less than the copayment for ultrasound. Ultrasound 
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 ultrasound on March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you would appreciate reconsideration 
of this drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 Entresto tablets.  
 
Benefits for self-administered drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography of the thorax, pelvis, and 
abdomen. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary as cancer runs in your 
enrollee's family history. The Plan denied your request. The Plan says this is being requested for screening 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that there is no support 
for this screening CT with a family history of colon cancer. 
 
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 scan have not been met. 
 
 
 
 
  
 Therefore, we decided that the Plan does not have to pre-approve computed tomography of the thorax, pelvis, 
and abdomen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that the requested admission to an IRF does not meet 
criteria. 
 
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. A request for information was sent to the Plan asking for medical records. We 
did not receive a response. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation 
facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rental months for oxygen concentrator and 
portable oxygen concentrator. 
 
You asked the Plan to pre-approve additional rental months for oxygen concentrator and portable oxygen 
concentrator. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
documentation indicates that the rental period is now capped. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment after 36 rental payments have been made. 
 
 
 
  
We looked at the file and Medicare rules. Review of the file shows that you have currently rented the oxygen 
concentrator and portable oxygen concentrator for 26 months. This means the equipment is now purchased 
owned. The documentation does not support that replacement items are being requested. Based on this 
information, we decided that Medicare rules for coverage of additional rental months for oxygen concentrator 
and portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional rental months for oxygen concentrator and portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for lab services provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from April 22, 2022, to May 2, 
2022. 
 
You asked the Plan to pay for infrared therapy. You say that the enrollee is entitled to all Medicare approved 
services. The Plan denied your request. The Plan says infrared therapy is not a covered service.  
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Specifically, per CMS, infrared devices are explicitly excluded 
from coverage. Therefore, we decided that the Plan does not have to pay for infrared therapy provided from 
April 22, 2022, to May 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on October 19, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you should not be responsible for this 
cost share. The Plan denied your request. The Plan says the cost share was applied 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 $95 
copayment for an MRI.  
 
You have been asked to pay $95 for an MRI. An MRI 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 
magnetic resonance imaging (MRI) provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used in 
this way and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam (92014) and refraction service 
(92015) provided on October 21, 2021. 
 You asked the Plan to pay for the vision care services. You say that this benefit was provided by an in-network 
provider. You say that it was processed as out-of-network. You also say that this should be reprocessed as in-
network. The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Routine eye exams received out-of-network are covered up to $75, 
you are responsible for any amount over $75. Based on this information, we decided that the Plan's rules for 
coverage of the vision care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the comprehensive exam (92014) and refraction service (92015) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic test provided on April 5, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic test. You say that you already paid a copayment 
and feel you should not have to pay a second copayment. The Plan denied your request. The Plan says the 
copayment applied was 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $20, which is less than the $50 for a diagnostic test. A 
diagnostic test 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 a diagnostic test provided on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit. 
 
You asked the Plan to pre-approve an office visit. You say that you are appealing the denial decision for an out-
of-network consultation visit. The Plan denied your request. The Plan says the service can be safely provided 
in-network. The plan says you were redirected to an in-network provider for a second opinion. 
 
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 
an office visit.