Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart (75574). 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the service is medically necessary. The 
Plan denied your request. The Plan says they did not receive medical information for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a CT scan of the heart have been met. 
There are no medical records in the case file. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan of the heart (75574).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mohs surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve Mohs surgery. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 
Mohs surgery to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel One. 
 
You asked the Plan to pre-approve Gel One. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Gel One. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has pain related to osteoarthritis of both knees, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One. The documentation does not support 
that Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel One.
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 admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure, sepsis, pneumonia and anemia. 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, in 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a HIFU procedure to be provided at an out-of-network 
(OON) facility. 
 
You asked the Plan to pre-approve a HIFU. You say that the requested OON facility is the only facility in the 
area with the equipment required to perform the procedure. The Plan denied your request. The Plan says the 
services requested can be performed at an in-network facility. 
 
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 facility in this case is not a network facility with the Plan. The Plan has network facilities 
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 
a HIFU procedure to be provided at an out-of-network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the advanced care planning services 
provided on June 16, 2022. 
 
You asked the Plan to waive the copayment for the advanced care planning services. You say that you should 
not be charged for a routine physical. 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 physician/practitioner services, including doctors office visits (primary care). 
 
You have been asked to pay a $10 copayment for the advanced care planning services. This item/service falls 
within the physician/practitioner services, including doctors office visits (primary 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.The records show the 
advanced care planning was provided in addition to the physical. This service goes beyond the scope of a routine physical and is subject to cost sharing. Therefore, we decided that the Plan does not have to waive the 
copayment for the advanced care planning services provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on July 05, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 each covered visit or consultation in an outpatient location with a specialist. Covered services 
include consultation, diagnosis, and treatment by a specialist. 
 
You have been asked to pay a $40 copayment for office visit. This item/service falls within the 
Physician/practitioner services, including doctor's 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 office visit on July 05, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from June 21, 2022, 
to June 30, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the services were observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from June 21, 2022, to June 30, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that the requested radiofrequency 
ablation (RFA) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested radiofrequency ablation (RFA). 
 
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 radiofrequency ablation (RFA). Our 
reviewer says that the enrollee does not meet criteria for the requested radiofrequency ablation (RFA). Our 
physician reviewer found there is documentation of at least two diagnostic medial branch blocks achieving at 
least 80% pain relief. There is no clear documentation of a second set of medial branch blocks. Therefore, the 
request is deemed not medically reasonable and necessary at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation (RFA) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA).
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 services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 there are no specified active medical comorbidities thus patient would not be expected to require continued inpatient hospitalization during rehabilitation. The complexity of the patient's 
nursing, medical and rehabilitation documented needs would not require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 2, 
2022. 
 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 September 2, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit with a computed 
tomography (CT) scan provided on June 07, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit with a computed tomography (CT) 
scan. You say that you should have been hospitalized the first time you were in the ER, and had to go back a 
second time. 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for an emergency room visit with a computed tomography (CT) 
scan. This item/service falls within the emergency care benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit with a computed tomography (CT) scan provided on June 07, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care from December 3, 2022, and forward. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital 
admission from December 3, 2022, and forward is medically necessary. The Plan denied your request. The 
Plan says that the requested inpatient hospital admission from December 3, 2022, and forward is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the requested inpatient hospital admission from December 3, 2022, and forward is medically 
necessary. Our physician reviewer found the review indicates that the enrollee was admitted to inpatient (IP) 
care on December 3, 2022, for comfort measures secondary to metastatic esophageal cancer. A request was 
made for the member to be admitted to IP care and was denied. Per the documentation, the enrollee presented 
to the medical floor from home, as his wife could not care for him at home any longer. He was recently 
discharged from another acute care hospital and his condition worsened at home. He was in extreme pain and 
could no longer swallow any medication, food, or water. He was treated with supplemental oxygen,  IV 
morphine, 6 mg every 2 hours, IV Ativan every 2 hours, and Scopolamine to control secretions. 
 
The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care from December 3, 2022, and forward.  
 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 Durysta. 
 
You asked the Plan to pre-approve Durysta. 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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Durysta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
the Durysta is medically reasonable and necessary for the enrollee. The enrollee has a diagnosis of corneal 
endothelial cell dystrophy, which is a contraindication based on the drug's prescribing information. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durysta.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Diagnostic radiology services provided on 
February 09, 2022. 
 
You asked the Plan to waive the copayment for Diagnostic radiology services. You say that this 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 $245 
copayment for Diagnostic radiology services. 
 
You have been asked to pay a $245 copayment for Diagnostic radiology services. This item/service falls within 
the Diagnostic radiology 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 
Diagnostic radiology services provided on February 09, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 04, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you cannot afford this 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 a $100 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $100 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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 surgery provided on August 04, 2022.