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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as 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 the enrollee was admitted for urinary tract infection and was discharged to skilled nursing on January 6, 2023. The enrollee's medical problems are stable, and 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. 
 
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 waive the coinsurance for therapeutic radiology services provided on 
June 7, 2022, to June 17, 2022. 
 
You asked the Plan to waive the coinsurance for therapeutic radiology services. You say that the cost-shares 
should only be $15.00 a visit. The Plan denied your request. The Plan says this cost sharing was charged 
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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay 20% coinsurance for each therapeutic radiology service. This item/service 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 coinsurance for therapeutic radiology services provided on June 7, 2022, to June 17, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing panel provided on December 
8, 2021. 
 
You asked the Plan to pay for the panel testing. You say that the results allow physicians to make treatment 
decisions. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the pharmacogenomics testing panel provided on December 8, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost sharing for the lab services. We decided that the Plan does not 
have to waive the cost sharing for the chest x-ray.  
 
You asked the Plan to waive the cost sharing for the chest x-ray and lab services provided on August 17, 2022. 
You say that these same services have always been covered in the past. The Plan says that this cost sharing was 
charged correctly. 
 
 We decided that the Plan has to waive the cost sharing for the lab services.  
 
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 enrollees must pay a $0 copayment for each Medicare-covered lab service. The 
Plan says you must pay a $6.84 copayment for lab services. Based on the Plan contract, however, you cannot 
be asked to pay more than $0 for lab services. Therefore, we decided that the Plan has to waive the copayment 
for the lab services. 
 
We also decided that the Plan does not have to waive the cost sharing for the chest x-ray. 
 
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 $35 
copayment for each Medicare-covered x-ray. 
 
You have been asked to pay a $28.16 copayment for a chest x-ray because the allowed amount for this service 
is less than $35. This item/service falls within the Medicare-covered x-ray 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 chest x-ray. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on August 
1, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you do not believe you 
should be responsible for this bill because you were misled by one of the staff members. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $0 
copayment for days 1-20 of a SNF stay. The contract also says that enrollees must pay a $188 copayment for 
days 21-100 of a SNF stay. 
 
You are not being charged for the first 20 days you were in the skilled nursing facility from July 12, 2022, to 
July 31, 2022. You have been asked to pay a $188 copayment for day 21 in the skilled nursing facility on 
August 1, 2022. You are also not being charged for the day you were discharged. August 1, 2022, was the twenty-first day of your skilled nursing facility stay. This item/service falls within the skilled nursing facility 
(SNF) 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 skilled nursing facility 
provided on August 1, 2022.  
 
Your complaint about being misled by the skilled nursing staff is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 7, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the records support the procedure. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral; second level (64494). 
 
You asked the Plan to pre-approve injections. You say that the provider is recommending injections as a 
medical necessity. The enrollee has a constant deep pain across his low back. The Plan denied your request. 
The Plan says the request is not medically necessary because the records show the enrollee does not have two 
(2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent 
minimum of 80% relief of primary pain. 
 
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 injections. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has decreased range of lumbar spine motion; pain on palpation as well as during 
facet loading tests and imaging that supports the diagnosis of facet arthropathy. No diagnostic blocks have been 
ordered. The request for therapeutic blocks is, at this time, not 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and 
injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating 
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit provided on August 15, 
2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you did not have a phone or 
in-person appointment. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for medical care or surgery services in a primary care physicians office. The Plan contract also 
says if your provider offers additional telehealth services, appropriate cost-sharing will apply based on the 
services rendered. 
 
 
 You have been asked to pay a $10 copayment for the telehealth visit. This item/service 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 telehealth visit provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share an office visit and a triamcinolone injection 
provided on July 19, 2022. 
 
You asked the Plan to waive the cost share for an office visit, including an injection. You say that you were 
told there was no charge. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare Part B prescription drugs and a $50 copayment for a specialist visit.  
 
You have been asked to pay $.26, which is 20% coinsurance of the allowed amount for the injection ($1.28 
allowed amount x 20% coinsurance = $.26).  This item/service falls within the Medicare Part B prescription 
drugs benefit category.  
 You have been asked to pay $50 copayment for a specialist visit. This item/service 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 cost share for an office visit and a triamcinolone injection on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99231 billed for date of service September 2, 2022. 
 
You asked the Plan to pay for code 99231. You say that this service is separately payable. The Plan denied 
your request. The Plan says code 99231 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that postoperative E&M services related to the 
surgery are not separately reportable by the anesthesia practitioner except when an anesthesiologist provides 
significant, separately identifiable ongoing critical care services. In this case, the records show that this same 
provider billed for an anesthesia procedure the day prior to this E&M service.  You have not billed this E&M 
service with any modifier to indicate that the service was separately identifiable from the procedure on the 
preceding day. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99231 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99231 billed for date of service September 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 documentation does not support medical necessity for admission to an IRF. 
You have no acute medical or rehabilitation complexity and have no acute rehabilitation nursing needs for an  
 IRF admission. While you would benefit from physical and occupational therapy, your rehabilitation needs can 
be safely met in an alternate and low intensity setting such as in-home with services. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 you have demonstrated steady progress with limited acute hospital rehabilitation. 
Intensive IRF based therapy is not 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR/TAVI) 
with prosthetic valve; percutaneous femoral artery approach with inpatient hospital admission (33361). 
 
You asked the Plan to pre-approve a TAVR procedure with inpatient admission. You say that you disagree 
with the denial. The Plan denied your request. The Plan says the requested procedure does not meet the 
requirements for approval. 
 
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 TAVR procedure with inpatient 
admission. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found at issue is the medical necessity of the requested TAVR in 
this enrollee. The most recent echocardiogram showed a peak velocity across the aortic valve of 3.5 m/s. The 
mean aortic valve gradient and aortic valve area index with stroke volume index are not provided. There is no 
murmur on examination. Guidelines would not support aortic valve replacement based on the submitted 
medical records. As a result, at this time the requested TAVR would not be considered medically necessary in 
this enrollee's clinical management based on the submitted 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 TAVR procedure with inpatient admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a transcatheter aortic valve replacement (TAVR/TAVI) with 
prosthetic valve; percutaneous femoral artery approach with inpatient hospital admission (33361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye exam (92004) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the vision care. You say that you have been following up with this provider. 
You say that you need another referral because you switched plans. The Plan denied your request. The Plan 
says there are network providers available to provide the requested service. 
 
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 confirmed there are 
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 eye exam (92004) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 18, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
believed it would be cheaper handling this at home versus at the hospital. You also say that you didn't realize 
you would be responsible for the full $600 if you did not go to the hospital. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 18, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Butalbital-Acetaminophen 50-325 mg tablet 
medication. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Butalbital-
Acetaminophen 50-325 mg tablet medication.  
 Benefits for this item may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.