Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office consultation (99203) with a Urology 
specialist. 
 
You asked the Plan to pre-approve the consultation. You say that you have a family history of enlarged prostate 
and do not want to let this change in your hormone levels go unevaluated by a urology specialist. The Plan 
denied your request. The Plan says the records do not support that the requested service is 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 the consultation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee is a 72 year old male with a history of BPH and ureteral 
calculi and negative prostate biopsy whose PSA was 2.5 in July 2020 and increased to 3.9 in February 2022. 
Per the documentation he has no BPH related symptoms. There is no specific clinical rationale for a Urology 
evaluation at this time. A repeat PSA should be obtained in 4-6 months. 
 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 consultation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the office consultation (99203) with a Urology specialist.
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 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 the patient was admitted for a stroke and was discharged on 5/13/22. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable 
expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment, office visit and x-
rays provided on December 20, 2021. 
 
You asked the Plan to pay for the chiropractic manipulative treatment, office visit and x-rays. You say that you 
saved the Plan money by not going to the hospital and you never thought of checking to see if they were in-
network. You say that paying this bill would be in both of your interests. The Plan denied your request. The 
Plan says the deductible applied correctly to the chiropractic manipulative treatment. The Plan also says the 
office visit and x-rays remain denied as the only covered chiropractic service is manual manipulation of the 
spine.  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 a $1,500 deductible that applies out-of-network chiropractic services 
 
The chiropractic manipulative treatment falls within the "Chiropractic services" benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible which applies to 
out-of-network chiropractic services. This cost sharing is a contractual obligation that had not been met at the 
time the chiropractic manipulative treatment was received on December 20, 2021. Therefore, $26.73 has been 
applied to the deductible. 
 
The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct 
a subluxation. The office visit and x-rays are not considered manual manipulation of the spine. Therefore, we 
decided that the Plan does not have to pay for the chiropractic manipulative treatment, office visit and x-rays 
provided on December 20, 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 IRF care is medically reasonable and necessary. 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 the patient was admitted for non-surgical management of an L2 fracture after a motor vehicle accident. Medical problems are stable. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In 
conclusion, there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that this is medically necessary 
for the enrollee's continued medical treatment. 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 repeat epidural steroid injection (ESI) when the 
first injection directly and significantly provided improvement of the condition being treated may be 
considered medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function. 
 
We looked at the file and Medicare rules. In this case, the record indicates that the last epidural steroid injection 
was performed less than 3 months before the repeat epidural steroid injection was requested. Based on this 
information, we decided that Medicare rules for coverage of a repeat epidural steroid injection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Libtayo. 
 
You asked the Plan to pre-approve Libtayo. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the requested drug is not medically necessary at this 
time. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Libtayo. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with squamous cell carcinoma (SCC) of the gingiva right submandibular. In this case, the requested 
use of Libtayo is not FDA-approved for the enrollees diagnosis. Libtayo is FDA approved for cutaneous head 
and neck and not oral cavity. In addition, the use of Libtayo is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal. The requested drug is 
not medically reasonable and necessary for the enrollee's condition.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Libtayo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Libtayo.
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 need rehab for your hip and you need to get back 
to your previous function. The Plan denied your request. The Plan says IRF care is not medically necessary and 
your needs can be met at a lower level of care such as in a skilled nursing facility. 
 
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 while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program such as 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 29, 2021, to January 7, 2022. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that the coverage on your plan changed 
on January 1, 2022, so you should only have been charged $700 for this stay. The Plan denied your request. 
The Plan says the copayment amount 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 $350 copayment per day for days 1 to 5 for each in-network inpatient stay at a tier 2 provider. This inpatient stay 
lasted 9 days, resulting in a copayment amount of $1,750. 
 
You have been asked to pay $350 copayment per day for days 1 to 5 for inpatient stay. Inpatient stay falls 
within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay provided from December 29, 2021, to January 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic catheter placement provided 
on February 18, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic catheter placement. You say that you do not want 
to pay the $45 copayment. The Plan denied your request. The Plan says you have been charged the correct 
copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for diagnostic services, per provider, per date of service.  
 
 
 
 
 
 You have been asked to pay a $45 copayment for a diagnostic catheter placement. The diagnostic catheter 
placement 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 catheter placement provided on February 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you wish to get these services in another state. 
The Plan denied your request. The Plan says the services have been requested from an out-of-network provider. 
 
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 to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric hoyer lift and incontinence supplies. 
 
You asked the Plan to pre-approve an electric hoyer lift and incontinence supplies. You say that the requested 
electric hoyer lift and incontinence supplies are medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested electric hoyer lift and incontinence supplies are not 
covered by Medicare or the Plan. 
 
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 an electric hoyer lift. Our reviewer says 
that the enrollee does not meet criteria for the requested electric hoyer lift. Our physician reviewer found 
Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. The documentation 
does not reveal a physical therapy evaluation indicating that an electrical lift is needed over a mechanical lift or 
that the electrical lift would be safe and effective for this enrollee. 
 
Medicare rules also state that incontinence supplies are not covered because they are hygienic items that are 
non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of these items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electric hoyer lift and incontinence supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an electric hoyer lift and incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee. The 
Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was 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 an office visit provided on January 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal and replacement of a defibrillator 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no indication that the enrollee's device is at the end of batter life or having lead problems. 
 
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 requested services. Our physician 
reviewer found that the enrollee has cardiomyopathy and ejection fraction 38%, with a defibrillator (ICD) in 
place. The request is to upgrade the enrollees system to a biventricular defibrillator (CRT-D) to allow for 
biventricular pacing. The enrollee has frequent premature ventricular contractions (PVCs).   She exhibits frequent ventricular pacing, for which the ICD base rate was recently lowered to allow for greater 
intrinsic atrioventricular conduction and reduced pacing frequency. Her electrocardiogram shows a narrow 
QRS complex. As such, she does not meet guideline criteria for biventricular pacing. In summary, there is 
insufficient documentation to support the medical necessity for removal of the dual-chamber defibrillator and 
replacement with a bi-ventricular defibrillator (CRT-D). 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the removal and replacement of a defibrillator
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that the requested OON provider has 
an office in the assisted living facility, and it would be very helpful to get therapy on-site. The Plan denied your 
request. The Plan says the requested provider is an OON provider and there are multiple in-network providers 
which provide the same quality of service and can service the enrollee in the residence they reside in. 
 
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 
the physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested facet joint injections. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer found 
according to the coverage criteria, intra-articular (IA) facet blocks are considered reasonable and necessary as a 
diagnostic test only if medial branch blocks (MBB) cannot be performed due to specific documented anatomic 
restrictions or there is an indication to proceed with therapeutic intra-articular injections. In this case, there are 
no documented restrictions provided in the medical record. The review has determined that the enrollee does 
not meet the LCD criteria for the requested facet joint injections. 
 
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 injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.