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

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve epidural. You say that the previous epidural did not do as much good, and 
having been without an epidural for 2 months you have never had pain like this. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct, because there has not been evidence of at 
least 3 months of adequate pain relief or improvement in function from the previous epidural. 
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injections may be covered if 
certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural. Our reviewer says that you do 
not meet the Medicare criteria for the requested epidural steroid injection. Our physician reviewer found the 
most recent epidural steroid injection in December 2021 only provided 10-15% relief of pain. Therefore, you 
do not meet the indications for a repeat epidural steroid injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on November 23, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the services were performed by a 
non-covered provider type. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. Medicare rules also say that auxiliary personnel furnishing acupuncture must be under the 
appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services performed were by a licensed 
acupuncturist. It does not appear that these services were performed under the appropriate level of supervision 
of a physician, physician assistant, or nurse practitioner/clinical nurse specialist as per Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on November 
23, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will not make the significant enough 
gains necessary to be able to return home safely if his care is provided at a lower level of care. The Plan denied 
your request. The Plan says that the enrollee can safely receive the services needed, in other settings. 
 
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.   
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness, 
altered mental status, uremia, and respiratory failure. The enrollees 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. 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. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided by a network 
provider on November 9, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the office visit was 
related to an automobile accident and should have been billed to the automobile insurance carrier. The Plan 
denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $40 
copayment per specialist visit.   
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctors office visits 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 the office visit provided by a network provider on November 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 10, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was your first visit with this 
PCP, and it should have been an annual physical with no copayment. The Plan denied your request. The Plan 
says the visit was a new patient visit and not an annual physical visit. Therefore, the proper copayment was 
applied for this service. 
 
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 $10 
copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care 
provider.  You have been asked to pay a $10 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctors office Visits 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 office visit provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 knee and foot coded as L5856, L58428, L5845, 
L5980 and L5986. 
 
You asked the Plan to pre-approve a K3 knee and foot. You say that based on the enrollee's past history, 
current condition, and desire to ambulate, a functional level of K3 is appropriate. The Plan denied your request. The Plan says the requested prosthesis exceeds the enrollee's need as the records do not support functional 
status of a K3 ambulator. 
 
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 a K3 knee and foot. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the physician's notes and medical record describe the patient as using a power 
scooter, wheelchair, and walker and not currently showing capability of having a K3 level of activity to justify 
this request. Therefore, this request for K3 knee and foot prosthesis will be considered not medically necessary 
based on the provided documentation. 
 
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 K3 knee and foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a K3 knee and foot coded as L5856, L58428, L5845, L5980 and L5986.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on July 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that the submission does not represent a duplicate 
procedure. The Plan denied your request. The Plan says the services were not billed as required by coding 
regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. An independent laboratory may not bill for the technical component of a 
physician pathology service furnished to a hospital outpatient. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the pathology services provided on July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 10, 2020, to December 22, 2020. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was admitted with urinary tract infection (UTI) and hypotension. 
Lactic acid was elevated but quickly normalized with initial fluids and antibiotics. Assessment did not reveal 
any organ dysfunction related to the infection and so does not meet criteria for sepsis. Therefore, the DRG 871 
is not appropriate and the more appropriate DRG is 690 (KIDNEY AND URINARY TRACT INFECTIONS 
WITHOUT MCC) according to the provided documentation and current guidelines.    
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 10, 2020, to December 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an x-ray examination of the spine, cervical 
(72040) rendered on October 28, 2021. 
 
You asked the Plan to waive the deductible for an x-ray examination of the spine, cervical. You say that you 
paid your copayment and are being charged over the Medicare amount. The Plan denied your request. The Plan 
says you were charged the correct cost sharing amount. 
 
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 $500 deductible which applies to certain items and services 
specifically listed in the Plan contract. The Plan deductible applies to an x-ray examination of the spine, 
cervical.  
 
You have been asked to pay $41.99 for an x-ray examination of the spine, cervical. An x-ray examination of 
the spine, cervical, that you asked the Plan to waive the deductible for falls within the benefit category 
outpatient diagnostic tests and therapeutic services and supplies.  
 The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which 
applies to an x-ray examination of the spine, cervical. This cost sharing is a contractual obligation that had not 
been met at the time an x-ray examination was received on October 28, 2021. Therefore, we decided that the 
Plan does not have to waive the deductible for an x-ray examination of the spine, cervical (72040) rendered on 
October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary visits provided on January 15, 2021, to April 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visits. You say that the state the enrollee is being treated in does 
not require an authorization for an assisted living visit. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for domiciliary visits provided on January 15, 2021, to April 23, 
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee 
does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis 
in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a 
skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee has ongoing medical issues such 
as his hypotension that would be best served in an IRF. The enrollee's functional level does not require skilled 
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF.  As a 
practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
facility setting. The enrollee's needs can continue to be managed in the current IRF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan provided by a network 
provider on October 27, 2021. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that this was an abdominal aortic 
aneurysm screening and should be a covered service with no copayment. The Plan denied your request. The 
Plan says you have been asked to pay the correct cost-sharing 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 $100 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-
network physician's office or at an in-network free-standing facility (such as a radiology center or medical 
clinic).  
 
You have been asked to pay a $100 copayment for the duplex scan. the duplex scan falls within the Medicare-
covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or 
at an in-network free-standing facility (such as a radiology center or medical clinic) benefit category. The 
record shows a diagnostic code for atherosclerosis which makes the duplex scan diagnostic in nature. 
 
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 duplex scan provided by a network provider on October 
27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on November 3, 
2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you waited too long to see a 
doctor so ended up leaving without receiving care. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 $50 
copayment for emergency care.  
 
The medical records show that you received emergency care on November 3, 2021. Therefore, you are 
responsible to pay the $50 copayment.  You have been asked to pay a $50 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided on 
November 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck 
provided on October 6, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you have never had a copayment 
for ultrasounds before and you cannot afford it. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $100 
copayment for ultrasounds.  
 
You have been asked to pay $92.77, which is less than the $100 copayment for the ultrasound. The 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 an ultrasound of the head and neck provided on October 6, 
2021.