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

 
We decided that the Plan does not have to pre-approve an out-of-network cardiology referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says these must be approved by the Primary Care Provider (PCP). 
 
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 out-of-network cardiology referral.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at 
the current hospital and the LTACH would offer no additional services. 
 
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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH level of care is appropriate for 
the enrollee's medical needs. The Plan denied your request. The Plan says the notes do not show that the 
enrollee is stable for transfer to an LTACH. The Plan says that the acute care hospital setting that the enrollee is 
currently in is more appropriate for care needs. 
 
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 has chronic end-stage COPD on AVAPS Trilogy ventilation at night 
with 4-5 L oxygen support at home and was admitted to the acute care hospital with COPD exacerbation and 
acute on chronic respiratory failure requiring high flow oxygen support, and antibiotics (later discontinued). 
Recent notes describe the enrollee as worsening again with unresponsiveness and has an overall poor 
prognosis. The enrollee appears to be now unstable again and requires additional acute care services that can be 
completed at the current facility until more stable. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary at this time as the 
enrollee is too unstable for transfer. Completion of treatment at the current facility is recommended until more 
stable. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463) on 
March 10, 2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you fell on ice 
which resulted in a T12 compression fracture. You say you were measured and fit for a belt to relieve pain in 
your back, and you want the Plan to pay for your medical care.  The Plan denied your request. The Plan says 
the copayment 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 $350 
copayment for Medicare-covered surgery or other services provided to you in an outpatient hospital setting.  
 
You have been asked to pay a $141 copayment for a hospital outpatient clinic visit. The service at issue falls 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers benefit category.  
 The allowed amount for the services you received is only $141, which is less than the contractually required 
cost-share of $350. You are only responsible to pay the lesser amount. 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 hospital outpatient clinic visit (G0463) on March 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271), Ondansetron (J2405), Paclitaxel 
Protein-Bound Particles (J9264), Carboplatin (J9045), and Aprepitant (J0185). 
 
You asked the Plan to pre-approve Keytruda, Ondansetron, Paclitaxel Protein-Bound Particles, Carboplatin, 
and Aprepitant. The Plan denied your request. The Plan says based on the noted disease progression while on 
Pembrolizumab maintenance therapy, the enrollee's clinical scenario does not meet the requirements of 
accepted use of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Keytruda, Ondansetron, Paclitaxel 
Protein-Bound Particles, Carboplatin, and Aprepitant. Our reviewer says that the combination of requested 
drugs is not medically reasonable and necessary. Our physician reviewer found the enrollee has progressed on 
immunotherapy and received Carboplatin based treatment twice already. Our reviewer also found that these 
drugs are not safe and effective for the enrollee. 
 
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, Ondansetron, Paclitaxel Protein-Bound Particles, Carboplatin, and 
Aprepitant have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271), Ondansetron (J2405), 
Paclitaxel Protein-Bound Particles (J9264), Carboplatin (J9045), and Aprepitant (J0185).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve diagnostic facet joint medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve facet joint MBBs. You say that this procedure is medically necessary for 
your condition. The Plan denied your request. The Plan says that the requirement for conservative care has not 
been satisfied. 
 
The Plan follows Medicare rules. Medicare rules say that in order for facet joint interventions to be covered, 
there must have been a documented failure to respond to noninvasive conservative care management. 
 
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 facet joint MBBs. Our reviewer says 
that the requested injection services are medically reasonable and necessary. Our physician reviewer found that 
you have chronic low back pain which is mostly axial. The record demonstrates that you have tried rest, ice, 
heat and non-steroidal anti-inflammatory drugs. The progress notes provided document that you have tried and 
failed physical therapy and other conservative therapy for 12 weeks. As the patient has failed physical therapy 
and other conservative therapy, the coverage rules for MBBs have been satisfied. The request is medically 
reasonable and 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 facet joint MBBs have been met. Therefore, we decided that the Plan has to pre-
approve diagnostic facet joint medial branch blocks (MBBs).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92960 billed for date of service May 6, 2021. 
 
You asked the Plan to pay for procedure code 92960. The Plan denied your request. The Plan says payment for 
code 92960 is bundled into payment for code 93656. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 92960 
is a column II code to column I code 93656. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 92960 billed for date of service May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on September 24, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately and supported in 
the record. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. This code also does not allow for more than one unit per day. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 18, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for critical care have not been met. Therefore, 
we decided that the Plan does not have to pay for critical care, first hour (99291) provided on September 24, 
2021.
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 enrollee would benefit from a continued therapy 
in an acute rehabilitation facility in order to return to prior baseline. The Plan denied your request. The Plan 
says based on Medicare guidelines and the information we have about the enrollee's condition they do not meet 
the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the enrollee was admitted for lumbar spinal stenosis and a urinary tract infection. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair and accessories (K0861, E2311, 
E007, E1012, E2361, E1028, E0955, E2620, E2622, E2313, E2377, E2620). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that your need for a 
group 3 power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan 
says that you do not have a medical need for multiple power options included with group 3 wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
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 a group 3 power wheelchair and 
accessories. Our reviewer says that the service is medically necessary. Our physician reviewer found you have 
an appropriate diagnosis for a group 3 power mobility device (functional ADL impairments not relieved by 
cane, walker or manual wheelchair due to hemiparesis and spasticity). You have been safely operating a power 
mobility device. Wheelchair evaluation states that you do not have adequate pressure relief with cushion alone. 
You have documented spasticity with the medical need for frequent position changes therefore, you meet 
criteria for a group 3 power wheelchair with power tilt, recline and elevating leg rests; and E2311 electronic 
connection, E2377 expandable controller and E2313 expandable controller harness thus 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  
a group 3 power wheelchair and accessories have been met. Therefore, we decided that the Plan has to pre-
approve a group 3 power wheelchair and accessories (K0861, E2311, E007, E1012, E2361, E1028, E0955, 
E2620, E2622, E2313, E2377, E2620).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on April 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that treatment decisions improve enrollee outcomes. 
The Plan denied your request. The Plan says the testing is not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records from the enrollees 
treating physician that clearly document the intent of the testing. There are not enough records to show how the 
results of the testing will impact this specific enrollees clinical management. Based on this information, we 
decided that the Medicare rules for coverage have been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing services provided on April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) 
provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a 
preventative service and should have a $0 copayment. The Plan denied your request. The Plan says this claim 
was processed correctly, and your copayment was assessed in accordance with your contract. 
 
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 $340 
copayment for outpatient surgery services provided in a network ambulatory surgical center.  
 
You have been asked to pay a $340 copayment for the diagnostic colonoscopy. A screening colonoscopy is one 
performed on someone who has no signs or symptoms which warrant concern. A screening would not involve 
specimen collection or the removal of lesions or polyps. A diagnostic colonoscopy is one that is provided to 
investigate symptoms or is provided in an enrollee who has had a history of symptoms or related disease. It is 
possible for a colonoscopy to start as a screening, then become diagnostic if it is discovered that further investigation needs to take place, or if there are lesions or polyps which need to be removed. In this case, the 
colonoscopy was billed with a diagnostic colonoscopy code, and it is indicated that there were bowel symptoms 
which were being investigated. A diagnostic colonoscopy is classified as a surgical procedure, and in this case 
the outpatient surgery service took place in a network ambulatory surgical center. 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 diagnostic colonoscopy (45378) provided on January 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request is not 
medically necessary because the enrollee has not failed the preferred viscosupplements for their arthritis. 
  
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 Euflexxa. Our reviewer says that 
Euflexxa is not reasonable and necessary. Our physician reviewer found the Plan requires a trial of Orthovisc, 
Synvisc or Synvisc One before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drug(s). Our reviewer also found that there is no documentation provided indicating that the 
Plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a specialist office visit and 
infliximab infusion provided on March 3, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the specialist visit and infusion. You say that 
you feel you should be reimbursed for the costs. The Plan denied your request. The Plan says the correct 
copayment and coinsurance were applied. 
 
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 specialist visits and a 20% coinsurance for Part B drugs.  
 
You have been asked to pay a $30 copayment for the specialist visit. The specialist visit falls within the Doctor 
Visits benefit category. You have also been asked to pay $786.20 for the infusion, which is 20% of the allowed 
amount ($3,931.00 allowed amount x 20% coinsurance = $786.20). The infusion falls within the Part B Drugs 
benefit category. The total for the visit is $816.20. 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 and 
coinsurance for a specialist office visit and infliximab infusion provided on March 3, 2022.