Persius/hicric huggingface dataset:
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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's condition does not meet the requirements for an 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 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 multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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. Medically necessary care can be provided in a different 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97750 billed for date of service August 2, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the records are complete. The Plan denied your 
request. The Plan says the billed code is not supported. 
 
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 97750 is physical performance test or measurement (eg, 
musculoskeletal, functional capacity), with written report, each 15 minutes. 
 
 We find that 6 units of CPT code 97750 is not supported in the medical record. The written report provided 
does not document and support 90 minutes spent on the testing services. 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 procedure code 97750 billed for date of service August 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service August 2, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. The 
documentation supports that this panel used the nucleic acid probe technique. There is no evidence that 
multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code 
with one unit of service should be used. Based on this information, we decided that Medicare rules for 
coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for 
the panel testing billed for date of service August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable contact lenses provided on August 21, 2023. 
 
You asked the Plan to pay for the disposable contact lenses. You say that you paid $45.98 and should receive a 
$200.00 credit for the rest of the service. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $200 benefit towards the purchase and fitting of eyeglasses and 
pair of lenses or contact lenses (one per calendar year). 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for contact lenses on February 8, 2023, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
disposable contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the 
disposable contact lenses provided on August 21, 2023.
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 requires an IRF admission. The Plan 
denied your request. The Plan says the IRF services requested 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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 multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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. Medically necessary care can be provided in a different 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 diltiazem. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 diltiazem.  
 
Benefits for the medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (33289, C2624). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is experimental and investigational. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found at this time, the 
CardioMEMS system would not be considered medically appropriate and 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (33289, C2624).
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 LTACH services. You say that the enrollee's best chance for a quicker 
recovery and more favorable outcome will be with an admission to the LTACH. The Plan denied your request. 
The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 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 does not require services at the LTACH that are not available at the acute 
care hospital. 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 Plan. Given there are offered alternatives, an LTACH admission is not 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 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 transfer to an out-of-network hospital. 
 
You asked the Plan to pre-approve transfer to an out-of-network hospital. You say that you need care and the 
only facility available with beds that could assist you was the out-of-network provider. The Plan denied your 
request. The Plan says the requested facility is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The records show you were admitted to the 
participating facility on December 15, 2023. Therefore, the argument that the Plans network providers were 
not accessible for urgently needed care has not been supported. We found no exception that would require the 
Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
transfer to an out-of-network hospital.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
  You asked the Plan to pre-approve SNF care. You say that you would like to gain strength back to go back 
home. The Plan denied your request. The Plan says you do not require complex daily nursing care and daily 
skilled rehabilitation therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on 
September 9, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that your doctor advised you 
to call the ambulance. The Plan denied your request. The Plan says the Medicare ambulance benefit is a 
transportation benefit and without a transport there is no payable service. 
 
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 September 9, 2023. 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 ambulance treatment without transport provided 
on September 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that the additional transportation 
services are medically necessary. The Plan denied your request. The Plan says the enrollee has exhausted their 
non-emergent transportation benefits. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plans maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional non-emergent transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on 
August 23, 2023. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you believed the amount due was a 
$25 copayment. The Plan denied your request. The Plan says this cost sharing was charged 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% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $287.82, which is less than 20% coinsurance of the allowed amount for the 
injection. This item/service 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 the denosumab injection provided on August 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
spinal canal. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the reviewed documentation indicates that that 
the enrollee has not seen their doctor within the last 60 days or that they have had a re-evaluation after their 
doctor asked them to increase their usage of diclofenac to twice daily with an in-office re-evaluation 
afterwards. There is no documentation of any abnormalities on neurological exam. The review has determined 
that the requested MRI is not medically reasonable or necessary. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower spinal canal.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the medical necessity of the requested CT 
scan of the abdomen has not been established in the submitted records. The services cannot be approved at this 
time. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the proctosigmoidoscopy and the specialist 
office visit provided on July 28, 2023. 
 
You asked the Plan to reduce the deductible for the proctosigmoidoscopy and the specialist office visit. You 
say that the Plan paid nothing towards the claim. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $600 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
 
 You have been asked to pay $120.95 towards your deductible for the proctosigmoidoscopy. You have also 
been asked to pay $86 towards your deductible for the specialist office visit. The services you asked the Plan to 
reduce the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $600 
deductible which applies to physician/practitioner services, including doctors office visits. This cost sharing is 
a contractual obligation that had not been met at the time the proctosigmoidoscopy and the office visit was 
received on July 28, 2023. Therefore, we decided that the Plan does not have to reduce the deductible for the 
proctosigmoidoscopy and the specialist office visit provided on July 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service June 21, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. The 
documentation supports that this panel used the nucleic acid probe technique. There is no evidence that 
multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a single code 
with one unit of service should be used. Based on this information, we decided that Medicare rules for 
coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay for 
the panel testing billed for date of service June 21, 2023.