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

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram report (93010) 
rendered on March 25, 2021. 
 
You asked the Plan to waive the copayment for an electrocardiogram report. You say that the enrollee has 
never had to pay for services at this provider's office, so you do not feel the enrollee should have to pay the 
$8.57. The Plan denied your request. The Plan says the enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $25 copayment for diagnostic procedures and tests provided in a specialist office.  
 
The enrollee has been asked to pay $8.57, which is less than the $25 copayment for an electrocardiogram 
report. An electrocardiogram report falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the  
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an electrocardiogram 
report (93010) rendered on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 the enrollee was admitted with hypoxic respiratory failure from Coronavirus 
(COVID-19) pneumonia. The record indicates that the enrollee is improving. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. 
The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not an acute complex medical diagnosis, and the enrollee does not require 
supervision by a rehabilitation physician. 
 
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 sepsis, urinary tract infection, and obstructive uropathy due to renal stone. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
was admitted for hypercapnic respiratory failure and continues to have bilateral infiltrates or atelectasis that 
prevents weaning attempts at this time due to desaturation to less than 90%. The enrollee continues to receive 
acute care services, and these have not been denied. The medical record does not indicate that the enrollee 
requires services that she is not currently receiving but that would be available at the LTACH facility. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an OnabotulinumtoxinA injection 
provided on June 14, 2021. 
 
You asked the Plan to waive the coinsurance for an OnabotulinumtoxinA injection. You say that the services 
should be covered in full because you have migraines and have a lot of doctor's appointments to go to. The Plan 
denied your request. The Plan says the cost sharing applied correctly based on 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 10% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 You have been asked to pay a 10% coinsurance for an OnabotulinumtoxinA injection (10% of $923.80 is 
$92.38). OnabotulinumtoxinA injections fall within the Medicare Part B prescription drugs benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for an OnabotulinumtoxinA injection provided on June 14, 
2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET with concurrently acquired CT for attenuation correction and 
anatomical localization imaging; skull base to mid-thigh (CPT code 78815), for the enrollee. 
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that it is not supported for the first staging (finding extent of disease) of 
prostate (a gland that surrounds the neck of the enrollee's bladder) cancer. 
 
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 PET scan. Our physician reviewer 
found this is approved for men at high risk for extracapsular spread before definitive treatment. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; 
skull base to mid-thigh (CPT code 78815), for the enrollee.  
 
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 Eliquis for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for treatment of atrial 
fibrillation. The Plan denied your request. The Plan says that this is not covered under Part B. 
 
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 Eliquis for the enrollee.  
 
Benefits for this drug 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for physical therapy provided by a participating 
provider. 
 
You asked the Plan to pre-approve for physical therapy. You say that 24 visits are medically necessary. The 
Plan denied your request. The Plan says they will approve 10 visits. The Plan says that the additional 14 are not 
medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 for physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has difficulty following commands and has had periods of 
disorientation. The records do not demonstrate that the unique skills of a professional therapist are required to 
safely and effectively provide treatment. These services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve for physical therapy provided by a participating provider.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you can receive the care you need in another setting. 
 
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. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. Our physician reviewer found 
that your condition does not meet Medicare criteria for LTACH 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 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 pay for inpatient hospital services with a reported secondary 
diagnosis code of E43, provided on June 4 - June 11, 2020. 
 
You asked the Plan to pay for the inpatient hospital services with a reported secondary diagnosis code of E43. 
You say that the documentation provided supports the diagnosis code billed. You say that severe malnutrition was supported by provider documentation with significant weight loss and exam consistent with severe 
malnutrition and nutrient supplements with appetite stimulants utilized during the encounter. The Plan denied 
your request. The Plan says the secondary diagnosis code was removed consistent with the documentation that 
was submitted. The Plan says that the documentation is unclear and conflicting regarding a confirmed 
diagnosis of severe protein-calorie malnutrition which required clarification from the provider prior to the final 
code assignment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a secondary diagnosis code of E43. 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 inpatient hospital services with a reported secondary 
diagnosis code of E43. Our reviewer says that the documentation does not support the reporting of E43 as a 
secondary diagnosis for this hospital admission. Our physician reviewer found the documentation supported an 
admission for further evaluation and treatment of central cord syndrome. While the discharge summary notes 
an exam consistent with severe malnutrition other provider documentation was unclear and/or inconsistent 
regarding this condition. The emergency department physical exam documentation includes, "He appears well-
developed and well-nourished." The discharge summary listed moderate malnutrition in the diagnostic list and 
notes exam consistent with severe malnutrition in the hospital course. The documentation was unclear and 
conflicting regarding a confirmed diagnosis of severe protein-calorie malnutrition and there was no further 
clarification from the provider.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services with a reported secondary diagnosis code of E43, provided on June 4 - June 11, 
2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve MPI. You say that the services are necessary. The Plan denied your request. 
The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the 
presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or 
abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered 
screening and denied as not covered by Medicare. 
 
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 MPI. Our reviewer says that the 
services are medically necessary. Our physician reviewer found stress testing to rule out coronary artery 
disease is appropriate and medically indicated in this clinical situation. The use of nuclear stress imaging is also 
appropriate based on the applicable LCD 33560 criteria for assessing the "functional and prognostic 
significance of angina." In addition, given her relatively high risk for coronary artery disease (advanced age, 
hypertension, hyperlipidemia, new onset atrial fibrillation) she would also meet this via medical reasonableness 
and necessity criteria. This is noted as an appropriate utilization of the nuclear imaging technology in the 
ACCF 2009 Nuclear stress testing guidelines (1)--even in the absence of baseline ECG abnormalities--in order 
to avoid the subsequent risk of a false negative finding on the less sensitive electrocardiogram (EKG) stress 
testing when the pre-test probability of coronary artery disease (CAD) is already intermediate to high. In these 
instances, the more sensitive test is most appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MPI have been met. Therefore, we decided that the Plan has to pre-approve 
myocardial perfusion imaging (MPI).  
 
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 Rhopressa for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that there is a risk of further vision loss and even 
blindness without aggressive eye pressure control. The Plan denied your request. The Plan says that this is not 
covered under Part B. 
 
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 Rhopressa for the enrollee.  
 
Benefits for this drug 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 pay for GeneSight testing (81291, 81479) provided on April 12, 
2021. 
 
You asked the Plan to pay for GeneSight testing. You say that this is a covered service. The Plan denied your 
request. The Plan says this was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that unless the record reflects that the treating 
clinician has already considered non-genetic factors to make a preliminary drug selection, pharmacogenomics 
(PGx) testing is not considered reasonable and necessary. The rules also say 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. Although the order for this testing marked that the treating physician 
already considered non-genetic factors, medical records were not submitted that document and confirm this 
information. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have 
not been met. Therefore, we decided that the Plan does not have to pay for GeneSight testing (81291, 81479) 
provided on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
  
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 LTACH services.