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 services are necessary to maximize the enrollee's 
independence. 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 necessity for admission to an IRF due to lack 
of medical or rehabilitation complexity with no acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be provided in a 
lower intensity and alternate setting such as in a skilled nursing facility or 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on July 07, 2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with the copaymet. 
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 outpatient diagnostic tests. 
 
You have been asked to pay a $10 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic 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 x-ray services provided on 
July 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the left hip. 
 
You asked the Plan to pre-approve an MRI of the left hip. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 of the left hip. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the MRI at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. Provided records do not document any red flags in the history, a 
physical examination of the enrollee with regard to the left hip pain or failure of a practitioner-directed course 
of conservative treatment for the pain. Records also do not document any plain x-ray imaging of the hip which 
demonstrates findings that require an MRI for further evaluation. 
 
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 of the left hip have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the left hip.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says that the 
requested services are available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rental months for an oxygen concentrator and 
a portable oxygen system. 
 
You asked the Plan to pre-approve additional rental months for an oxygen concentrator and a portable oxygen 
system. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan 
says the enrollee has exhausted the 36-month rental benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment after 36 rental payments have been made. 
 
We looked at the file and Medicare rules. Review of the file shows that you have currently rented the oxygen 
concentrator and portable oxygen system for 36 months. This means the equipment is now purchased owned. 
The documentation does not support that replacement items are being requested. Based on this information, we 
decided that Medicare rules for coverage of additional rental months for an oxygen concentrator and a portable oxygen system have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
rental months for an oxygen concentrator and a portable oxygen system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab. 
 
You asked the Plan to pre-approve durvalumab. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve durvalumab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the use of durvalumab FDA-approved for 
the enrollees diagnosis. The enrollee may have advanced disease beyond stage III and there is no evidence of 
response to treatment with chemoradiation. The use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of durvalumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve durvalumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dexamethasone injection with ultrasound guidance provided 
on September 07, 2022. 
 
You asked the Plan to pay for dexamethasone injection with ultrasound guidance. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for dexamethasone injection 
with ultrasound guidance provided on September 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee procedure provided on September 23, 2022. 
 
You asked the Plan to pay for a knee procedure. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a knee procedure 
provided on September 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
October 5, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. 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 $125 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $125 copayment for outpatient diagnostic tests. However, you are being asked to 
pay $124.42 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered radiological diagnostic services 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 outpatient diagnostic tests provided on October 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on August 31, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgery provided on 
August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network acute inpatient stay 
provided from September 6, 2022, to September 7, 2022. 
 
You asked the Plan to waive the coinsurance for an acute inpatient stay. You say that you are on a fixed income 
and cannot afford this payment. You were not informed of this cost share amount. 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 15% 
coinsurance for inpatient hospital care. The allowed amount of this services was $5,762.58, resulting in a 
coinsurance of $864.39 ($5,762.58 x 15% = $864.39). 
 
You have been asked to pay an $864.39 coinsurance for an acute inpatient stay. This item/service falls within 
the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an in-
network acute inpatient stay provided from September 6, 2022, to September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tolvaptan. 
 
You asked the Plan to pre-approve Tolvaptan. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Tolvaptan.  
 
Benefits for Tolvaptan 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: 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 requires inpatient rehab due to end stage 
renal disease with new initiation of hemodialysis. You say that the enrollee will require physician monitoring, 
blood pressure monitoring, and pain management. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollees needs can be met at an alternate 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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit for physical and occupational therapy the enrollee's needs can be provided in an alternate setting such as 
skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 8, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says per Medicare, the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations and the date of consultations in the patients medical 
record. If consultation with the attending or primary care physician is unsuccessful, document the patients 
medical chart with the date and manner of notification to the physician. There was no documented contact with 
the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid genomic laboratory testing provided on September 
15, 2022. 
 
You asked the Plan to pay for thyroid genomic laboratory testing. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for thyroid genomic 
laboratory testing provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on September 15, 
2022. 
 
You asked the Plan to pay for skilled nursing facility services. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
services provided on September 15, 2022.