Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF 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 that the complexity of the enrollees 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 pulmonary embolism and retroperitoneal hematoma. The 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 enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cast supplies provided to the enrollee on December 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support this service. 
 
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, the CPT Code Manual definition of code Q4038 is "Cast supplies, short leg cast, adult (11 years 
+), fiberglass." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
document cast supplies; short leg cast adult. To cite the report "Dry protective dressing on the right daily". In 
this case, this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for cast supplies provided to the enrollee on December 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about your condition; you don't meet the requirements. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for altered mental status and urinary tract infection. Your medical problems are stable. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implantation of wireless pulmonary 
artery pressure sensor for long-term monitoring (33289) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the device is medically necessary due to old 
myocardial infection. 
 The Plan denied your request. The Plan says the device is investigational in this setting. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transcatheter implantation of wireless pulmonary artery pressure sensor for long-term 
monitoring (33289) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Botox injections provided on December 
13, 2021. 
 
You asked the Plan to waive the coinsurance for Botox injections. You say that you cannot afford this bill and 
the price has doubled from last year. The Plan denied your request. The Plan says the coinsurance was 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 20% for 
each Medicare-covered Part B drug obtained in a provider's office or outpatient setting for the Botox injections. 
The allowed amount was $1,217, resulting in a coinsurance of $243.40.   
 
You have been asked to pay a total of $243.40 for the Botox injections. Botox injections falls 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 
Botox injections provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman FLX LAAC device implant procedure 
(33340, 93312). 
 
You asked the Plan to pre-approve the Watchman procedure. You say that this letter documents the medical 
necessity for this therapy and provided information about the enrollee's medical history and treatment as well 
as a description of the procedure. The Plan denied your request. The Plan says there is lack of documentation 
that the enrollee is 'deemed unable to take long term oral anticoagulation as LAAC is only covered as a second 
line therapy to oral anticoagulants. 
 
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 the Watchman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has an elevated risk of thromboembolic stroke due to atrial fibrillation 
and elevated CHADS2VASC score. There is no apparent contraindication to anticoagulation. As such, 
guidelines would not support implantation of a LAAC in this setting. In summary, LAAC placement would not 
be considered reasonable or medically necessary in this enrollees clinical management. 
 
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 Watchman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Watchman FLX LAAC device implant procedure (33340, 93312).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve transfer handles. We decided that the Plan does not have to pre-
approve a power seat elevation system, an expandable controller, harness, and an electronic connection.  
 
You asked the Plan to pre-approve transfer handles. You say that the services are necessary. The Plan says that 
based on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve transfer handles.  
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 transfer handles. Our reviewer says that 
the services are medically necessary. Our physician reviewer found that transfer handles are medically 
necessary due to safety with transfers specifically addressed by provider.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transfer handles have been met. Therefore, we decided that the Plan has to pre-
approve transfer handles.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system, an 
expandable controller, harness, and an electronic connection. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 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 power seat elevation system, an 
expandable controller, harness, and an electronic connection. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the documentation does not support the medical need for 
the services requested. 
 
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 power seat elevation system, an expandable controller, harness, and an 
electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation system, an expandable controller, harness, and an electronic connection. 
 
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 Freestyle Libre 14 day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. 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 therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14 day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency destruction of nerves supplying joint 
between spine and pelvis using imaging guidance (Left SI joint Radiofrequency Ablation) X1. 
 
You asked the Plan to pre-approve radiofrequency destruction of nerves supplying joint between spine and 
pelvis using imaging guidance (Left SI joint Radiofrequency Ablation) X1. The Plan denied your request. The 
Plan says radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging 
guidance (Left SI joint Radiofrequency Ablation) X1 are not medically necessary. 
 
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 destruction of nerves 
supplying joint between spine and pelvis using imaging guidance (Left SI joint Radiofrequency Ablation) X1. 
Our reviewer says that the requested radiofrequency destruction of nerves supplying joint between spine and pelvis using imaging guidance (Left SI joint Radiofrequency Ablation) X1 are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the service is considered an experimental/ 
investigational procedure because of the wide variation in efficacy. Therefore, the request is deemed 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 radiofrequency destruction of nerves supplying joint between spine and pelvis 
using imaging guidance (Left SI joint Radiofrequency Ablation) X1 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency destruction of nerves supplying joint between spine 
and pelvis using imaging guidance (Left SI joint Radiofrequency Ablation) X1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug administration services provided on July 27, 2021, 
billed with code 96413. 
 
You asked the Plan to pay for the drug administration services as billed. You say that this was billed correctly 
and should be paid. The Plan denied your request. The Plan says an inappropriate code was reported for these 
services. 
 
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, the CPT Code Manual definition of code 96413 is Chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
We asked our coder 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 drug administration services as billed. Our reviewer says 
that the reported CPT code is not supported in the record. Our reviewer found the documentation supports Orencia 750mg was administered intravenously for Rheumatoid arthritis. In this case, there is a more 
appropriate code to report for rheumatoid arthritis administration.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug administration services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug administration services provided on July 27, 2021, 
billed with code 96413.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on November 12, 
2021. 
 
You asked the Plan to waive the copayment for lab services. You say that the EOC doesn't mention if lab work 
is included in the annual physical exam or not. The Plan denied your request. The Plan says the copayment was 
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 $10 per 
day for other Medicare-covered laboratory tests that are not FIT tests (screening test for colon cancer).  
 You have been asked to pay $10 for lab services. Lab services 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 waive the copayment for 
lab services provided on November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from 
August 19, 2021, to August 23, 2021. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that when you were 
admitted you were told you would only stay one day, and the hospital kept you for five days. 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 $325 
copayment per day for days 1-6 for an inpatient hospital stay. The contract also says that there is a $0 
copayment for additional days. The Plan contract also says that enrollees must pay a $7,550 maximum out-of-
pocket (MOOP) per calendar year. 
 
The record shows you had met your MOOP during the processing of this claim. You have been asked to pay a 
total of $1,580, which is less than the $325 copayment per day for days 1-5 for an inpatient hospital stay. There 
is no charge on the day of discharge. An inpatient hospital stay 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 reduce the copayment for an inpatient hospital stay provided from 
August 19, 2021, to August 23, 2021.
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 January 1, 2022, to January 5, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that your hospitalization has not been 
covered. 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 $90 
copayment for an emergency room visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$90 copayment for an ER visit. An ER visit falls within the Emergency Care 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 
January 1, 2022, to January 5, 2022.
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 is too weak to care for himself since he 
lives at home alone. He needs therapy to gain strength and also assistance cleaning trach. The Plan denied your 
request. The Plan says the records do not support that the enrollee meets the Medicare 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 enrollee was admitted for angioedema, respiratory failure, tracheostomy, and 
aspiration pneumonia. 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 enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not 
a reasonable expectation that 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 acute inpatient rehabilitation facility (IRF) admission and services.