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

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided 
from September 30, 2021, to October 1, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that your doctor informed you that you 
were going to be admitted as an inpatient, and should not have a copayment. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 and post-stabilization care.  
 
 
 The file shows that you were evaluated and treated in the emergency room. The file does not show evidence 
that a written order was submitted by the doctor to admit you as an inpatient. Therefore, you have been asked 
to pay a $100 copayment for the ER visit. The ER visit 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 (ER) visit provided from September 30, 
2021, to October 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 28, 2021, to October 27, 2021. 
 
You asked the Plan to pay for the SNF services. You say that these services should be covered. The Plan 
denied your request. The Plan says the enrollee did not receive skilled nursing services during this time frame. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found during this SNF stay, the enrollee 
received services such as nursing assessments and administration of oral medications. No other skilled nursing 
services were provided such as complex wound care. The enrollee did not receive rehabilitation services during 
this time frame which would be considered skilled services by Medicare. The enrollee did not receive a 
frequency of skilled therapy services warranting SNF level of care during the time frame under review. He only 
received occasional physical and occupational therapy and his nursing care was routine. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from September 28, 2021, to October 27, 
2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0829-59 billed for date of service December 7, 2021. 
 
You asked the Plan to pay for procedure code G0829-59. You say that you billed this service correctly and 
payment is due. The Plan denied your request. The Plan says that the use of the -59 modifier is not supported in 
the medical record, so no separate payment for this code is due. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code G0829-59 Our reviewer says 
that the use of the -59 modifier is supported by the medical record. Our physician reviewer found the operative 
report describes arthroscopy of the right knee to include lateral and medial meniscectomy, and chrondroplasty 
of patella, medial compartment, both performed on the right knee, in different compartments.  To cite the 
report: "Next, my assistant brought the leg into extension to allow work in the patellofemoral joint. My 
assistant varied flexion to aid in exposure. The shaver was brought to the patellofemoral joint, where a 
chondroplasty of the trochlea and patella was performed. Loose flaps were tapered to a stable surface.  The 
knee was then copiously irrigated, lavaged and drained. Per CMS, G0829 can be reported separately if reported 
for removal of a loose body or foreign body from a different compartment of the same knee."  In this case, 
loose body was removed from a different compartment.  Therefore, the use of the -59 modifier is supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0829-59 have been met. Therefore, we decided that the Plan 
has to pay for procedure code G0829-59 billed for date of service December 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid sinus baroreflex activation device and 
generator. 
 
You asked the Plan to pre-approve carotid sinus baroreflex activation device and generator. You say that this is 
medically necessary. The Plan denied your request. The Plan says this device is not medically necessary for the 
patient because it has not been proven safe and effective by medical studies. 
 
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 carotid sinus baroreflex activation 
device and generator. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the Barostim Neo is an implantable pulse-
generator system which gained Food and Drug Administration (FDA) approval in August of 2019 for the 
management of reduced-ejection-fraction heart failure deemed unsuitable for other device therapies.  
 
 
 The Barostim Neo System is indicated for the improvement of symptoms of heart failure for patients who 
remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III or Class II 
(who had a recent history of Class III), have a left ventricular ejection fraction = 35%, a NT-proBNP < 1600 
pg/ml and excluding patients indicated for Cardiac Resynchronization Therapy (CRT). The case file does not 
contain a current NT-proBNP 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 carotid sinus baroreflex activation device and generator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a carotid sinus baroreflex activation device 
and generator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital admission provided from 
November 2, 2021, to November 4, 2021. 
 
You asked the Plan to waive the copayment for the hospital admission. You say that you don't understand what 
you are paying for. The Plan denied your request. The Plan says the copayment applied 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 $350 per 
day for days 1 to 5 and $0 after day 5 each time you are admitted to an acute care hospital. 
 
  You have been asked to pay a total of $700 ($350 x 2 days = $700).  Inpatient hospital admission 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 copayment for the inpatient 
hospital admission provided from November 2, 2021, to November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) care. 
 
You asked the Plan to pre-approve IRF care. 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 the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of IRF care have not been met. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not 
have to pre-approve inpatient rehabilitation facility (IRF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung 
cancer screening. 
 
You asked the Plan to pre-approve a LDCT for lung cancer screening. 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 follows Medicare rules. Medicare rules say that beneficiaries must meet specific criteria for a LDCT 
for lung cancer screening. 
 
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 LDCT for lung cancer screening. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has a known pulmonary nodule. The record does not indicate the enrollee's smoking status. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 LDCT for lung cancer screening have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) for lung cancer 
screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network benefit coverage for a lumbar fusion to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve in-network benefit coverage for a lumbar fusion to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
in-network benefit coverage for a lumbar fusion to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested drug have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Retacrit. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
available documentation supports that Retacrit is safe and effective for the enrollee and that Retacrit is 
medically reasonable and necessary 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 Retacrit have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Retacrit (Q5106).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide.. You say that you have muscular dystrophy that is progressing, 
youre unable to lift your legs to get up the stairs into the kitchen. Also, you have osteoporosis in your right 
hip/femur, that you're very afraid of falling. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cardiac catheterization test provided on 
October 1, 2021. 
 
You asked the Plan to reduce the copayment for the cardiac catheterization. You say that your copayment 
should only be $40. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $45 
copayment per provider, per date of service, for routine radiology.  
 
You have been asked to pay a $45 copayment for the cardiac catheterization. The cardiac catheterization 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 reduce the copayment for a cardiac catheterization test provided on October 1, 2021.
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 enrollee had IRF care last year for two weeks, 
and he made significant progress. You say the enrollee has fallen several times and he is motivated to make 
progress. The Plan denied your request. The Plan says authorization denied because IRF care is not medically 
necessary, and the enrollee's needs can be met 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 the enrollee is medically stable and does not need close physician supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. There are no rehabilitation nursing needs identified or documented in the record. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided you are stable and do not meet criteria for 
LTACH transfer. You do not require services at the LTACH that are not already available at the current 
facility. There are no services at the LTACH that you require that are not already available and covered at the 
current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing needs are identified or 
documented in the available record. 
 
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: 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 admission is medically necessary. The Plan 
denied your request. The Plan says the requested admission 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 the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs. The reviewer found that while the enrollee has a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the requested IRF 
admission is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.