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 requested IRF care is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical necessity 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a king size adjustable bed. 
 
You asked the Plan to pre-approve a king size adjustable bed. You say that a king size adjustable bed is 
medically necessary. The Plan denied your request. The Plan says commercially sold beds such as a king size 
adjustable bed are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say equipment must be provided by Medicare eligible providers. Medicare does not 
cover commercially sold adjustable beds. This bed does not serve a purpose that is primarily medical in nature. 
This item is available to the public and would be helpful even to those who are not sick or injured. Therefore, 
we decided that the Plan does not have to pre-approve a king size adjustable bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prostate Specific Antigen (PSA) testing provided on 
October 28, 2021. 
 
You asked the Plan to pay for the PSA testing. You say that you would like reconsideration because this testing 
was medically necessary. The Plan denied your request. The Plan says this testing is covered once every 12 
months. 
 
The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen tests are 
covered at a frequency of once every 12 months for men who have attained age 50. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PSA testing have not been met. Specifically, the documentation indicates that you had PSA 
testing provided less than 12 months prior to the date of service at issue. This testing is covered once every 12 
months. Therefore, we decided that the Plan does not have to pay for the Prostate Specific Antigen (PSA) 
testing provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ankle foot orthosis, plastic or other material with ankle joint, 
prefabricated, includes fitting and adjustment (L1971) prefabricated, off-the-shelf, foot, plastic, silicone or 
equal, heel stabilizer (L3170) provided December 13, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that please see attached medical records. The Plan denied 
your request. The Plan says this item is not a covered benefit. Evidence of misrepresentation. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition.  Therefore, we decided that the Plan does not have to pay for Ankle foot orthosis, plastic or other material with 
ankle joint, prefabricated, includes fitting and adjustment (L1971) prefabricated, off-the-shelf, foot, plastic, 
silicone or equal, heel stabilizer (L3170) provided December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75571 billed for date of service December 9, 
2021. 
 You asked the Plan to pay for procedure code 75571. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 75571 is bundled into payment for 
code 71260. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 75571 
is a column II code to column I code 71260. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 75571 billed for date of service December 9, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) any joint of lower 
extremity. 
 
You asked the Plan to pre-approve an MRI. You say that an MRI is medically necessary. The Plan denied your 
request. The Plan says there was no recent x-ray to have your knee evaluated, which is required before an MRI 
should be requested. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that an MRI 
is not medically necessary. Our physician reviewer found there is no physical exam of the left knee after the 
enrollees fall in the records. There is no x ray result. There is no red flag is presented to mandate immediate 
MRI absent a conservative trial of therapy including physical therapy. 
 
 
 
 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) any joint of lower extremity.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail zoledronic acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of zoledronic 
acid first before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug(s). There is no documentation provided indicating that the Plans required drug(s) would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on 
December 7, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $15 
copayment for each specialist visit for Medicare-covered services.  
 
You have been asked to pay a $15 copayment for the Medicare-covered specialist visit provided. 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 (99203) provided on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the positron emission tomography (PET) 
scan (78815) provided on December 10, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $195 
copayment for advanced imaging services provided by an in-network outpatient hospital.  
 
 You have been asked to pay a $195 copayment for the advanced imaging service provided by an in-network 
outpatient hospital. 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 positron emission 
tomography (PET) scan (78815) provided on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair and raised toilet seat. You say that these items are medically 
necessary. The Plan denied your request. The Plan says these items are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair and raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and 
raised toilet seat.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 6, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 6, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) on July 27, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are not 
contracted with the facility or the prescribing physician and do not receive payment from either provider. The 
Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
In this case the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for 
a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Prolia first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Prolia 
first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required 
drug(s). There is no documentation provided indicating that the Plans required drugs would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (93306). 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that the enrollee requires yearly 
diagnostic testing for heart failure with reduced ejection fraction. The Plan denied your request. The Plan says 
this test is not medically necessary because the records do not show that the enrollee is having new or 
worsening symptoms. 
 
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 transthoracic echocardiography. Our 
reviewer says that there is no supportive evidence for the medical necessity of a repeat transthoracic 
echocardiography in this this patients clinical management. Our physician reviewer found at issue is the 
medical necessity of a repeat transthoracic echocardiography, in the absence of any apparent significant change 
in the patients clinical condition. Our reviewer also found that clinical guidelines do not support repeating a 
transthoracic echocardiography with no intervening change in clinical status or physical findings. 
 
 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 transthoracic echocardiography have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiography (93306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits (99211, 99213) and the 
laboratory services (80053, 82378, 85025, 86300) provided from June 1, 2021, through August 4, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $20 
copayment for each Medicare-covered specialist visit and a $40 copayment for each Medicare-covered lab 
service.  
  
 
You have been asked to pay $100 ($60 + $20 + $20). This amount includes a $60 copayment for the office visit 
and laboratory services provided on June 1, 2021, a $20 copayment for the specialist visit provided on July 7, 
2021, and a $20 copayment for the specialist visit provided on August 4, 2021. 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 copayments for the office visits (99211, 99213) and the laboratory services (80053, 82378, 85025, 
86300) provided from June 1, 2021, through August 4, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to adjust the copayment from $40 to $35 for the x-ray exam of the ankle (73610) 
and the x-ray exam of the foot (73630) provided on November 15, 2021. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the services provided. 
 
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 $35 copayment for basic radiology services provided at an 
urgent care center.  
 
The Plan says you must pay $40 ($33.62 + $6.38) for the basic radiology services provided. Based on the Plan 
contract, however, you cannot be asked to pay more than a $35 copayment for basic radiology services 
provided at an urgent care center. The radiology services in this case were performed on the same visit, from 
the same urgent care facility and doctor. Therefore, we decided that the Plan has to adjust the copayment from 
$40 to $35 for the x-ray exam of the ankle (73610) and the x-ray exam of the foot (73630) provided on  
November 15, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan drops. 
 
You asked the Plan to pre-approve Zioptan drops. The Plan denied your request. The Plan says self-
administered drugs are covered by the pharmacy (drug) 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 drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan drops.  
 
Benefits for Zioptan drops may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81455). 
 
You asked the Plan to pre-approve the genetic testing. You say that this test is medically necessary.. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for this service to be covered, for patients that do not 
have a diagnosis of a myeloid malignancy, where one is suspected, the patient must have an undefined 
cytopenia for greater than 4 months. 
 
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 genetic testing. Our reviewer says 
that this testing is not medically necessary. Our physician reviewer found the record does not show cytopenia 
for more than 4 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81455).