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

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that patient has multiple comorbidities which would be expected to require 
to require close medical supervision. Evaluating therapists (PT, OT and SLP) all recommend intense therapy 
thus IRF criteria has been met and is medically 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 been met. Therefore, we decided that the Plan has to pre-approve 
an IRF admission and services.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit and 
prescription drug charges provided on May 15, 2022, to May 16, 2022. You asked the Plan to waive the copayment for an emergency department visit. You say that you never asked 
for these services, and you were sent to the hospital against your will. The Plan denied your request. The Plan 
says  the cost share applied was correct. 
 
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 In-Network Emergency Services. The rules say that Medicare Part B generally does not pay for 
self-administered drugs. 
 
You have been asked to pay a $90 copayment for an emergency department visit. An emergency department 
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. Additionally, 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 waive the 
copayment for an emergency department visit and prescription drug charges provided on May 15, 2022, to May 
16, 2022.  
 
Benefits for self-administered drugs may be available through Medicare Part D prescription drug benefits. 
Please contact the plan that administers the enrollees Medicare Part D prescription drug benefits for more 
information.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on June 7, 2022. 
 
You asked the Plan to waive the copayment for eye surgery. You say that no one told you about the copayment. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $400 
copayment for surgical services in an ambulatory surgical center.  
 
You have been asked to pay $400 copayment for eye surgery. Eye surgery falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 eye surgery provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 25, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that after the injection you couldn't walk 
and was in severe pain so you dont think you should have to pay for that. The Plan denied your request. The 
Plan says the coinsurance applied is correct. 
 
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% 
coinsurance for other Medicare Part B covered drugs.  
 
You have been asked to pay $425.80 which is 20% of the allowed amount for an injection. The allowed amount 
is $2,129.01(20% x $2,129.01=$425.80). 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 injection provided on April 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Multaq 400mg tablets. 
 
You asked the Plan to pre-approve the Multaq. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Multaq 400mg tablets.  
 
Benefits for the Multaq 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 the pathology services provided on January 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services are the standard of care. The 
Plan denied your request. The Plan says the service is included in the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 We looked at the file and the rules. Pathology services were provided to the enrollee as a hospital outpatient. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the pathology services provided on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service January 3, 
2022. 
 
You asked the Plan to pay for procedure code 12001. You say that the medical records support payment of this 
code. The Plan denied your request. The Plan says payment for code 12001 is bundled into payment for code 
31500. 
 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 12001 
is a column II code to column I code 31500. 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 12001 billed for date of service January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on April 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 5 identifies codes that describe services covered incident to a physicians service and are 
payable when performed in the inpatient setting. 
 
We looked at the file and Medicare rules. The billed procedure codes have a PC/TC indicator of 5 and were 
performed in the outpatient hospital setting. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing services rendered on April 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Viper Plus manual wheelchair and accessories. 
 
You asked the Plan to pre-approve a Viper Plus manual wheelchair and accessories. You say that you are 
unable to walk without someone holding and helping you. You say that you need to go to the doctor and cannot 
without someone walking with you. You say that you have a doctor appointment, need to pick up your 
medications, and go buy food. The Plan denied your request. The Plan says the wheelchair being requested is 
not intended for use inside of your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Viper Plus manual wheelchair and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on the date 
in question The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 32550. 
 
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 71045 
is a column II code to column I code 32550. 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 71045 billed for date of service April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urinalysis services (procedure code 81015) provided to the enrollee on August 10, 2020.

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 an edit exists between 81015 and 81000.

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 81015 is a column II code to column I code 81000 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for urinalysis services (procedure code 81015) provided to the enrollee on August 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for occupational therapy provided on March 1, 
2022 and March 8, 2022. 
 
You asked the Plan to reduce the copayment for occupational therapy. You say that you were quoted a $10 
charge for OT and were not informed that charges for modalities and other treatment techniques were charged 
separately. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $35 
copayment for in-network Medicare-covered occupational therapy services. There were two visits, resulting in 
a total copayment amount of $70. 
 
You have been asked to pay a $35 copayment for each occupational therapy visit. Occupational therapy falls 
within the Outpatient Rehabilitation 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 reduce the copayment for occupational therapy provided 
on March 1, 2022 and March 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that this claim was processed incorrectly, and 
no copayment should be charged. 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 a $165 
copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear 
scans and PET scans, per date of service. 
 
You have been asked to pay $165 for an MRI. An MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies (PA) 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 a Magnetic Resonance Imaging (MRI) scan provided on March 16, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physician's supervision 3 times a 
week in an IRF. Based upon the current level of function, the enrollee does not require an intensive, complex, 
multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program 
consisting of at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach to 
rehabilitation care. There are no documented acute rehabilitation nursing needs. While the enrollee may benefit 
from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and 
lower intensity setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 64430 provided on April 22, 
2022. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
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 64430 is injection(s), anesthetic agent(s) and/or steroid; 
pudendal nerve. 
 
We find that CPT code 64430 is not supported in the medical record. Specifically, this code was not billed with 
an anatomical modifier. Based on this information, we decided that Medicare rules for coverage of the injection 
services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services 
coded 64430 provided on April 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Rituxan or Ruxience. 
 
 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 Truxima. Our physician reviewer found 
that the enrollee has diffuse large B-cell lymphoma. The requested medication is a new start. The provided 
records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's 
preferred step one alternative. The elements of the coverage criteria are not satisfied. Therefore, 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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 26, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. 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 each emergency room visit.  
 
You have been asked to pay a $90 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 on May 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that this claim was processed incorrectly, and 
no copayment should be charged. 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 a $165 
copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear 
scans and PET scans, per date of service.  
 
You have been asked to pay $165 for an MRI. An MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies (PA) 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 a Magnetic Resonance Imaging (MRI) scan provided on March 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 14, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were misdiagnosed and 
shouldn't have to pay for it. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $150 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic.  
 
You have been asked to pay $150 copayment for an ultrasound. Ultrasounds fall 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 an ultrasound provided on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 24, 2022.