Persius/hicric huggingface dataset:
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 the enrollee is an ideal IRF candidate due to their 
ability to recover/regain significant functional improvement. You say that this warrants a level of intervention 
that only inpatient rehabilitation can provide. The Plan denied your request. The Plan says the criteria for 
admission to the IRF 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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While 
the medical record supports a need for physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 4, 2022, to March 2, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you have been seeing this provider for quite a few 
years. You also say that you always have this trouble. The Plan denied your request. The Plan says the services 
rendered with this provider were rendered out-of-network and without a valid referral on file from your 
primary care physician (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 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 psychotherapy provided on January 4, 2022, to 
March 2, 2022, by an out-of-network (OON) provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 surgical repair of an ankle fracture after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental for back pain. More research is needed before 
coverage can be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve dental services. You say that you are not able to drink anything. The Plan 
denied your request. The Plan says the services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The file shows that a cyst removal was requested. This service is included in the approved tooth extraction. 
Facial surgery and sedation were also requested. Although the Plan offers a dental benefit in excess of 
Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve dental services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nerve and muscle testing provided on May 
12, 2022. 
 
You asked the Plan to waive the copayment for nerve and muscle testing. You say that the evidence of 
coverage is not clear on how much you would be charged so it should be covered. 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 $95 
copayment for All other diagnostic procedures and tests. 
 
You have been asked to pay a $95 copayment for nerve and muscle testing. This item/service falls within the 
All other diagnostic procedures and tests 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 nerve and muscle testing provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88360, 88381, 88341 and 88342 billed for 
date of service January 7, 2022. 
 
You asked the Plan to pay for procedure codes 88360, 88381, 88341 and 88342. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
services were not billed in accordance with Medicare coding guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88360, 88381, 88341 and 88342 are pathology services which have both professional 
components (PC) and technical components. These services were not billed with modifier 26 to indicate that 
only the professional component payment is requested. This means that payment is requested for both the PC 
and TC of these services. However, these services were provided to an enrollee who was in an outpatient 
hospital setting at the time the sample was collected, which means that the TC component is bundled into the 
facility payment. The TC portion of these services are not separately payable, and therefore these services are 
not supported as billed. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 88360, 88381, 88341 and 88342 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 88360, 88381, 88341 and 88342 billed for date of service January 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery in the left eye. 
 
You asked the Plan to pre-approve cataract surgery in the left eye. You say that you do not agree with the 20/20 
vision assessment, as your vision is blurry, and you cannot see clearly now. The Plan denied your request. The 
Plan says your sight is 20/20 and the requested surgery is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that lens extraction is covered when medically necessary 
for certain clinical indications.  
 
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 cataract surgery in the left eye. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the visual acuity 
in the left eye is correctable to 20/20, and there is no documentation of reduced vision from glare.  Manifest 
refraction indicates vision is correctable to 20/20 L eye; there is no documentation you have failed corrective 
lenses. The fundus is well visualized, and the cataract is not interfering with any retinal condition visualization. 
There is also no documented anisometropia after surgery for the first eye. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cataract surgery in the left eye have not been met. Therefore, we decided that 
the Plan does not have to pre-approve cataract surgery in the left eye.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a leuprolide acetate suspension provided 
on May 25, 2022. 
 
You asked the Plan to reduce the coinsurance for a leuprolide acetate suspension. You say that this is excessive 
billing for the 20% coinsurance for Medicare Part B drugs. 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 drugs.  
 
You have been asked to pay $202.43 in coinsurance, which is 20% of the allowed amount for a leuprolide 
acetate suspension ($1012.14 x 20% = $202.43). This item/service falls within the Medicare Part B drugs 
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 reduce the coinsurance for a leuprolide acetate suspension 
provided on May 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan for therapy guide provided on 
April 26, 2022. 
 
You asked the Plan to waive the copayment for a CT scan for therapy guide. You say that the scan was ordered 
by your provider as part of your treatment. You say that the Plan paid $0 towards the claim, and you would like 
a review. 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 $60 
copayment for each Medicare-covered radiation therapy service.  
 
 
  You have been asked to pay $48.91, which is less than the standard $60 copayment for a CT scan for therapy 
guide. 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 copayment for a CT scan for therapy guide 
provided on April 26, 2022.
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 would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for admission to the acute 
inpatient rehabilitation setting 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 enrollee does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different level of 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.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0431), and rotary wing air mileage (A0436) provided on October 25, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that the enrollee revoked their hospice 
election to pursue treatment. You also say that this should be covered. The Plan denied your request. The Plan 
says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B 
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to 
know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. 
Additionally, though the enrollee ended Medicare Hospice benefits on the date of service in thiscase. The 
services in question were provided before the end of that month. Therefore, we decided that the Plan does not 
have to pay for the ambulance service, conventional air services, transport, one way (A0431), and rotary wing 
air mileage (A0436) provided on October 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 06, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you say that the ultrasound was 
part of the office visit and you should not be charged a double copay. You say that you have floaters and are a 
high risk for retina tears. 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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for an ultrasound. 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 
copayment for an ultrasound provided on July 06, 2022.
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 this is the best treatment for your diagnosis. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have not been met. Your ongoing 
skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy on an intensive IRF level. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784), ultraviolet lenses (V2755), 
tint (V2744), and anti-reflective coating (V2750) received on June 17, 2022. 
 You asked the Plan to pay for polycarbonate lenses, ultraviolet lenses, tint, and anti-reflective coating. You say 
that the items are medically necessary, and you want the Plan to pay for them. The Plan denied your request. 
The Plan says the enhancements are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The Plan does not cover enhancements. Based on this information, 
we decided that the Plan's rules for coverage of polycarbonate lenses, ultraviolet lenses, tint, and anti-reflective 
coating have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses 
(V2784), ultraviolet lenses (V2755), tint (V2744), and anti-reflective coating (V2750) received on June 17, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services provided on 
November 18, 2021. 
 
You asked the Plan to pay for the CxBladder genetic testing services. You say that you would like this claim 
reprocessed for medical necessity. The Plan denied your request. The Plan says this testing is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy in place for 
CxBladder genetic testing services. Based on this information, we decided that Medicare rules for coverage of 
the CxBladder genetic testing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the CxBladder genetic testing services provided on November 18, 2021.