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 you are currently experiencing numbness in your 
finger and hand, have been in the hospital for about a week with no physical therapy which is causing you to 
lose morbidity and function in right arm. The Plan denied your request. The Plan says your records show that it 
is not reasonable to expect that you will be able to safely participate in, or fully benefit from, the intensity of 
services of an IRF. The Plan says that the services needed may be provided safely in a lower level of care.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 principal care management services provided on May 16, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that the enrollee was in a nursing 
home setting at the time services were rendered. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for principal care 
management services provided on May 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 29, 2022, to 
May 3, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as sepsis, 
unspecified organism, and secondary diagnosis codes R65.20, described as severe sepsis without septic shock, 
and J96.01, described as acute respiratory failure with hypoxia. We asked our physician reviewer to carefully 
review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the 
request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that 
documentation does not support the billed diagnosis codes. Our physician reviewer found that the enrollee 
presented with cough, weakness, body aches, chills, and nasal drainage. Review of systems was negative for 
confusion or other systemic symptoms except chills, cough, congestion, and shortness of breath. Vital signs 
showed a temperature of 37.8 degrees Celsius, respiratory rate of 24, pulse 85 and blood pressure 158/76. 
Oxygen saturation 96%. Her white blood cell count was 14,800 with a carbon dioxide (CO2) of 21 and normal 
renal and liver function and a normal lactic acid. A chest X-ray was concerning for a right-sided pneumonia. 
She was treated with a one-liter fluid bolus and ceftriaxone and 2 liters oxygen. She experienced a prompt 
normalization of her white count. Blood cultures were negative. Her working diagnosis through the remainder 
of the hospital course was community-acquired pneumonia. Provided records do not meet criteria for a 
principal diagnosis code A41.9, and secondary diagnosis codes R65.20 and J96.01.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 29, 2022, to May 3, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on October 7, 
2022. 
 
You asked the Plan to pay for a neuromuscular stimulator. You say that you have billed the item at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
  We find that CPT code E0745 is not supported. Specifically, Medicare records indicate that the item denoted 
by code E0745 is required to be reported with an "RR" modifier. The case record does not support that an "RR" 
modifier was reported in this case. Based on this information, we decided that Medicare rules for coverage of a 
neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for a 
neuromuscular stimulator (E0745) provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 31, 2023, by an  
out-of-network provider.  
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 31, 2023, by an  
out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36561-RT billed for March 13, 2023. 
 
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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 49440 
provided on March 7, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 36561-RT billed for 
March 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy injections provided on 
November 28, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy injections. You say that you disagree with the 
cost share applied. 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 20% coinsurance for chemotherapy injections. 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. The total you owe is $209.21, which is 20% of the allowed amount for Medicare 
Part B drug injections ($1,046.05 allowed x 20% = $209.21). Therefore, we decided that the Plan does not have 
to waive the coinsurance for chemotherapy injections provided on November 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 1, 2023, 
to March 19, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the copayment 
applied because the services provided were medically necessary. 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 $0 
copayment per day for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
You have been asked to pay a total copayment of $2,595 for a SNF stay. This total includes a $188 copayment 
for the SNF stay provided January 1, 2023, to January 3, 2023, which is less than the standard amount for a 
SNF visit, and a $2,407 copayment for the SNF stay provided March 4, 2023, to March 19, 2023, which is less 
than you standard copayment because your maximum out-of-pocket was met with the processing of this claim 
($196 per day x 15 days = $2,940). This item/service falls within the SNF 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 a SNF stay provided from January 1, 2023, to March 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 21, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says this provider is out-of-network and authorization was not 
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 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 an office visit provided on March 21, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on March 20, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) additional external urethral clamps or 
compression device (A4356). 
 
You asked the Plan to pre-approve additional external urethral clamps. You say that you need the additional 
clamps, because when you wash them, they fall apart so the one per month does not meet your needs. The Plan 
denied your request. The Plan says the standard number of penile claims for a three-month period is (1) to 
adequately meet your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that one external urethral clamp or compression 
device is covered every 3 months or sooner if the rubber/foam casing deteriorates.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional external urethral clamps have not been met. Therefore, we decided that the Plan does not 
have to pre-approve twenty (20) additional external urethral clamps or compression device (A4356).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation services to be provided by a non-
Plan vendor. 
 
You asked the Plan to pre-approve routine transportation services. You say that the requested services are a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage of routine 
transportation have not been met.  
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 routine transportation when provided by the Plan provider.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the request is for 
routine transportation services from a non-approved provider. Additionally, the Plan has documented that the 
routine transportation benefit through the Plan provider has not yet been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve routine transportation services to be provided by a non-Plan vendor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new office visit provided on April 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a new office visit. You say that you are transferring from your old primary care 
provider (PCP) to this provider. They are my new PCP and therefore should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
 
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 new office visit provided on April 18, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiology visit provided on May 10, 2023. 
 
You asked the Plan to pay for a cardiology visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a cardiology visit 
provided on May 10, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show rehabilitation needs are 
complex. The Plan says that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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: Favorable

 
We decided that the Plan has to pre-approve Provenge injections. 
 
You asked the Plan to pre-approve Provenge injections. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet the criteria for the requested drug 
to be approved. 
 
The Plan must follow Medicare rules. The rules say that CMS and Medicare will pay for the drug if found to be 
reasonable and necessary for the on-label indication under 1862(a)(1)(A) of the Social Security Act.  
 
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 Provenge injections. Our reviewer says 
that the requested drug, Provenge, meets the necessary criteria for approval. Our physician reviewer found that 
you have prostate cancer that has spread to other parts of the body and has not responded to hormone therapy 
which cause minimal or no symptoms. Therefore, the requested drug is medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Provenge injections have been met. Therefore, we decided that the Plan has to 
pre-approve Provenge injections.  
 
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: 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's goal is to return home and they need 
intensive rehabilitation under medical supervision. The Plan denied your request. The Plan says IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care.  
 
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 no acute rehabilitation nursing needs were 
identified or documented. The complexity of the enrollee's needs does not require an acute hospital inpatient 
rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollee's needs can be safely 
provided in an alternate and low 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.