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 the member meets full criteria for an inpatient 
rehabilitation stay. 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 17 home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you have 
received home health physical therapy and your level of function has not changed with continued therapy. You 
and your caregivers have been instructed in terms of a home exercise program to reduce muscle tone and 
maintain range of motion. The services of a skilled physical therapist are not indicated and 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 17 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 04, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you have been seen by this 
provider before and feel you should not have to pay the 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 a $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on November 04, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network mental health inpatient 
hospital stay provided on December 29, 2021. 
 
You asked the Plan to waive the copayment for an in-network mental health inpatient hospital stay. You say 
that you were made to stay longer, and feel you should not have to pay the 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 a $300 
copayment for inpatient mental health care. 
 
You have been asked to pay a $300 copayment for an in-network mental health inpatient hospital stay. This 
item/service falls within the inpatient mental health 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. You have a $750 deductible, as well as a $300 copayment for 
an inpatient admission. The number of days is not relevant in this situation. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network mental health inpatient hospital stay provided on 
December 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 20, 2023. 
 
You asked the Plan to pay for a home visit. You say that this is supported in the records. 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 home visit provided on 
January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on December 
12, 2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that due to your primary care 
provider being booked for the day, you went to urgent care. 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 a $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 15, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on November 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammogram and digital breast tomosynthesis 
provided on October 26, 2022. 
 
You asked the Plan to pay for a screening mammogram and digital breast tomosynthesis. You say that this is 
supported in the records. 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 screening 
mammogram and digital breast tomosynthesis provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colostomy and initial hospital care provided on November 
23, 2022.  
You asked the Plan to pay for a colostomy and initial hospital care. You say that the claim should be 
reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a colostomy and initial hospital care provided on November 
23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 1, 2023. 
 You asked the Plan to pay for ambulance services. You say that the enrollee was disenrolled from hospice at 
the time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-compounded foam (NCF) sclerotherapy, for 
treatment of other incompetent extremity veins (36470). 
 
You asked the Plan to pre-approve sclerotherapy procedure. You say that please consider this pertinent medical 
history to consider coverage of bilateral greater saphenous vein VenaSeal and sclerotherapy. The Plan denied 
your request. The Plan says the documentation does not support that the Medicare criteria has been met.  
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 sclerotherapy procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not meet coverage criteria. For tributary treatment such as 
sclerotherapy to be considered medically necessary per coverage criteria, there needs to be persistent 
significant symptoms following successful treatment of truncal (saphenous) reflux with these symptoms 
existing more than 6 weeks after the reflux was treated and despite conservative efforts.  Additionally, the veins 
to be treated need to be at least 4 mm in diameter. As the enrollee has not yet undergone saphenous vein reflux 
treatment, the above criteria have not been met. The health Plan does not provide for simultaneous saphenous 
reflux treatment and tributary treatment. A rationale for this is that many patients experience satisfactory relief 
with the truncal intervention alone. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the non-compounded foam (NCF) sclerotherapy, for treatment of other 
incompetent extremity veins (36470).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no specific indication provided 
to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-
term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
additional services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered under 
certain medical indications.   
 
We looked at the file and Medicare rules. The Plan has agreed to cover a one-month course of treatment. 
Medicare rules say that wounds must be evaluated at least every 30 days. Based on this information, we 
decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional hyperbaric oxygen therapy.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient hospital admission for a total right shoulder arthroplasty. 
 
You asked the Plan to pre-approve inpatient hospital admission. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that the requested inpatient admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 inpatient hospital admission. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee was being treated for arthropathies not elsewhere classified.  
Detailed documentation is evident regarding a significant past and/or current medical history that would place 
this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. The enrollee's past 
medical history included hypertension, hypothyroidism, obesity, sleep apnea, arthritis, asthma, 
gastroesophageal reflux disease, high cholesterol, low back arthritis, and psoriasis. The enrollee has a history of 
a heart valve procedure. The record does show that the admitting physician reasonably would expect the 
enrollees necessary hospital care would span two midnights. Therefore, the enrollee does meet criteria for the 
requested inpatient admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital admission have been met. Therefore, we decided that the Plan 
has to pre-approve inpatient hospital admission for a total right shoulder arthroplasty.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nanOss 3D advanced bone graft substitute. 
 
You asked the Plan to pre-approve nanOss 3D advanced bone graft substitute. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve nanOss 3D advanced bone graft 
substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for spinal stenosis of the 
lumbar region with neurogenic claudication and radiculopathy of the lumbar spine. Past surgical history was 
positive for T11-12 decompression in January 2014. 
 
Conservative treatment included home therapy, activity modification, rest, heat, epidural steroid injection, 
physical therapy, chiropractic treatment, and medications. However, the notes indicate the possibility of a 
fusion at more than one level. Additionally, there is limited published, large-scale, long-term peer-reviewed 
literature that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. 
Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional 
treatment. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested nanOss 3D advanced bone graft 
substitute, in this case, 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 nanOss 3D advanced bone graft substitute have not been met. Therefore, we 
decided that the Plan does not have to pre-approve nanOss 3D advanced bone graft substitute.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82728, 83540, and 83550) related to 
end-stage renal disease (ESRD) provided on November 4, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. 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 (82728, 83540, and 83550) related to end-stage renal disease 
(ESRD) provided on November 4, 2022.