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

 
We decided that the Plan does not have to pay for [complete description of item or service at issue, e.g. at issue 
is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."] 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that the services were medically necessary. The Plan denied your request. The Plan says this service is 
not covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. Genetic cardiovascular screening is not covered under Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of [Shorter description of ITEM 
or SERVICE at issue, e.g. "a power wheelchair"] have not been met. Therefore, we decided that the Plan does not have to pay for [complete description of item or service at issue, e.g. at issue is "a power wheelchair 
provided by The Wheelchair Store on January 12, 2016."]
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation from January 28, 
2022, to February 4, 2022. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation from January 28, 2022, to February 4, 
2022. You say that you were told these services would be covered. The Plan denied your request. The Plan says 
for days 1-5 of inpatient hospital care, you pay a copayment of $275 per day. 
 
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 for days 1-5, you must 
pay a $275 per day copayment for Inpatient Hospital Care. There were 7 days of inpatient rehabilitation; 
however, the copayment only applies to the first 5 days, resulting in a total copayment amount of $1375 
($275x5=$1375).  
 You have been asked to pay a $1375 copayment for inpatient rehabilitation. Inpatient rehabilitation 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  inpatient 
rehabilitation from January 28, 2022, to February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement performed  
January 31, 2022, to February 21, 2022. 
 
You asked the Plan to waive the copayments for wound debridement performed January 31, 2022, to   
 February 21, 2022. You say that your wound is healing, but it will take time and you are requesting a 
permanent reduction in your copayment. The Plan denied your request. The Plan says you must pay $200 for 
each Medicare-covered ambulatory surgical center visit. 
 
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 $200 
copayment for Outpatient Surgery Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. There were 4 visits, resulting in a total copayment amount of $800. 
 
You have been asked to pay a $200 copayment for wound debridement performed January 31, 2022, to   
February 21, 2022. Wound debridement 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 copayments for wound debridement performed January 31, 2022, to February 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says the records show you fell and did not want to be transported to the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lesion shaving provided on January 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the lesion shaving. You say that you have been seeing this doctor for years and 
you would like to have your appointment covered. You say your provider would like to be a participating 
doctor. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
lesion shaving. We found no exception that would require the Plan to pay for the lesion shaving. The record 
shows the provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the lesion 
shaving provided on January 31, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) from an out-of-network provider. 
 
You asked the Plan to pre-approve PT. You say that it only takes five minutes to walk to the out-of-network 
provider. The Plan denied your request. The Plan says the available medical information does not support the 
need for an authorization to a non-plan provider. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide PT. Under Medicare rules, this 
means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-
approve physical therapy (PT) from an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a capsulectomy provided on September 10, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a capsulectomy. You say that you were not aware that you needed prior 
authorization for the procedure. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a capsulectomy provided on September 10, 2021 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on March 29, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you were not aware that the maximum benefit limits had been reached for these services. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefits for the requested services were exhausted on date of service November 23, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) provided on March 29, 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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services requested are 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 member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The member can 
receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the enrollee has tried oral iron in the past. You also 
say that they were not absorbing it. The Plan denied your request. The Plan says the requested drug is not 
medically necessary. 
 
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 Injectafer. Our reviewer says that the 
coverage criteria for Injectafer have not been met. Our physician reviewer found the record does not indicate 
that a trial of oral iron has been unsuccessful at this time. The reviewer found that the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the reviewer found that the elements of the coverage criteria are not 
satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy services. 
 
You asked the Plan to pre-approve aquatic therapy. You say that you are unable to walk by yourself, and you 
require aquatic therapy to regain strength and mobility. The Plan denied your request. The Plan says aquatic 
therapy may be considered reasonable and necessary for someone without the ability to tolerate land-based 
exercises for rehabilitation. In addition, you are only able to obtain services from out-of-network providers if the services are 
urgent/emergent and not available within your medical network. You would be able to tolerate land therapy 
from an in-network provider; therefore, the requested aquatic therapy is not medically necessary in this case. 
 
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 aquatic therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that you have a history of chronic low back pain and lumbar spondylosis. A clinical progress 
note from June 1, 2022, indicates that you continue to have low back pain that radiates into both legs. The pain 
is worse when sitting and better when laying down and with medication. You are noted to have limited range of 
motion of the lumbar spine and pain with lumbar extension. The recommendation was for physical therapy, 
including aquatic physical therapy. Conventional or land based physical therapy is typically indicated in 
patients with chronic low back pain and lumbar spondylosis. Aquatic therapy is typically reserved for people 
with a diagnosis of fibromyalgia, rheumatoid arthritis, or significant hip osteoarthritis that impairs the ability to 
ambulate. There is no clinical documentation indicating that you cannot participate in land based physical 
therapy. Aquatic therapy would not be considered more beneficial than an existing and available medically 
appropriate treatment, specifically land based physical therapy. Therefore, the requested aquatic therapy cannot 
be considered 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 aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve aquatic therapy 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 enrollee needs intensive rehabilitation to get back 
to their previous level. The Plan denied your request. The Plan says the documentation does not show that the 
enrollee needs a rehabilitation doctor at least 3 times a week or that they need an intensive team for care. The 
services the enrollee needs can be provided in other setting like a skilled nursing facility, home health services, 
or home with outpatient therapy. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The 
enrollee's medical status does not require intensive physician and nursing oversight in an IRF. There were no 
updated lab studies of renal function and potassium levels noted in the chart since July 15, 2022, indicating that 
these values are improved, and the enrollee is medically optimized for a rehabilitation program.   
 
While the enrollee may benefit from additional multiple therapies, including physical and occupational therapy, 
the documentation does not reveal that the enrollee requires this therapy on an intensive IRF level or can 
tolerate an the therapy on an intense level. He is already ambulating 300 feet at standby assist and the therapy 
note recommended home physical therapy. Furthermore, the enrollee is noted to have significant fatigue which 
does not support the need for an intensive rehab program. 
 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services 
for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that you do not have complex rehab needs and do not need to see a 
rehab doctor 3 times a week. 
 
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. Clinical documentation 
shows that the patient has active comorbidities and hospital complications and would benefit from close 
medical supervision on an inpatient basis. Evaluating therapists state that patient would benefit from intense 
therapy and can tolerate three hours of therapy per day. Our physician reviewer found that the enrollee's 
condition meets Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says PCR testing is considered unproven 
and not eligible for payment. 
 
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 pay for the urine PCR panel testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found PCR urinary tract infection testing is considered investigational/experimental. Urine 
PCR amplification techniques raise considerable concerns regarding contamination from one specimen to 
another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging.  Amplification of organisms representing latent infection or colonization cannot be distinguished 
from active, clinically significant infections.  Additionally, PCR may amplify fragments of nucleic acids, 
representing dead microorganisms, thus further clouding the clinical interpretation.  Finally, specificities, 
sensitivities, and positive and negative predictive values of PCR have not been reported in large groups of 
patients for many of the microorganisms. The requested services were not medically reasonable and 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 the urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on July 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office services. You say that the enrollee did not provide the office staff with 
an insurance card and told you that his Medicare plan was correct. The Plan denied your request. The Plan says 
no prior authorization was obtained. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office services. We found no exception that would require the Plan to pay for the office services. Therefore, we 
decided that the Plan does not have to pay for the office services provided on July 27, 2021, by an out-of-
network (OON) provider.