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 medical records provided support the need for 
care in an IRF. The Plan denied your request. The Plan says that admission to an IRF is not medically 
necessary and does not meet the criteria for coverage.  
 
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. The enrollee 
was admitted for right sided weakness. There are no complex nursing or rehabilitation needs. 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the medication is medically necessary due to the 
enrollee's nausea from a urinary tract infection. 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 Ondansetron.  
 
Benefits for Ondansetron 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 18, 2023, to July 
31, 2023. 
 
You asked the Plan to pay for the home health services. You say that you believe you are an in-network 
provider, so this claim should be paid. The Plan denied your request. The Plan says you billed this claim with 
an incorrect Type of Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).  
Based on this rule, you should have billed this claim with a Type of Bill code of 0329.  Instead, you billed with 
code 0322, which is not correct. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from July 18, 2023, to July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgical repair procedure provided on 
April 28, 2023. 
 
You asked the Plan to waive the copayment for the surgical repair procedure. You say that you should not be 
charged twice for this service. 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 $40 
copayment for physician/practitioner services, including doctors office visits.  
You have been asked to pay a $40 copayment for the surgical repair procedure. 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 the surgical repair procedure provided on April 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gocovri capsules. 
 
You asked the Plan to pre-approve the medication. You say that this medication is medically necessary and 
appropriate for this 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 Gocovri capsules.  
 
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 pay for code 20611-78 billed for date of service August 4, 2023. 
 
You asked the Plan to pay for code 20611. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says code 20611-78 is not supported by the medical record. The 
medical records that an incision and drainage procedure was performed, so there is a different code that should 
have been billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 26011 is Arthrocentesis, aspiration and/or injection, 
major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting. 
 
 We asked our coder 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 code 20611. Our reviewer says that code 20611-78 is not 
supported by the medical record. Our reviewer found the medical record does not include documentation of 
arthrocentesis.  The procedure report documents "Procedure Performed: drainage abscess right hand with 
removal 3 k wires".  For 20611, a needle with a syringe attached is inserted into the affected joint or bursa. 
Fluid is removed and sent for separately reportable laboratory analysis. There is a more specific code that 
should be reported for documented service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 20611 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 20611-78 billed for date of service August 4, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc Syringe 
 You asked the Plan to pre-approve Synvisc Syringe. You say that you have been constructively denied the 
administration of hyaluronic acid to the left knee, which is a long term problem. The Plan denied your request. 
The Plan says the enrollee must have tried and failed Euflexxa and Gel-one. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc Syringe. Our reviewer says that 
the enrollee does not meet the criteria for the requested drug. Our physician reviewer found the Plan requires a 
trial of drugs Euflexxa and Gel-one before they will approve the requested drug. Our physician reviewer also 
found that you have not tried and failed the required drugs. Our physician reviewer also found that there is no 
documentation provided indicating that plans required drugs would likely be less effective and/or likely have 
adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc Syringe have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Synvisc Syringe
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external ambulatory infusion pump (E0784). 
 
You asked the Plan to pre-approve an external ambulatory infusion pump. You say that documentation was 
submitted to support the medical necessity for the requested insulin pump. The Plan denied your request. The 
Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an external ambulatory infusion pump may be 
covered when the criteria listed in the Medicare rules sections are met. 
 
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 an external ambulatory infusion pump. 
Our reviewer says that this item is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating that you meet the criteria for coverage for an insulin pump. The review has 
determined that requested external ambulatory infusion pump is not medically necessary or 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 an external ambulatory infusion pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external ambulatory infusion pump (E0784).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve luspatercept-aamt. 
 
You asked the Plan to pre-approve luspatercept-aamt. You say that the requested drug is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the use of Reblozyl for low grade 
myelodysplastic syndrome with ring sideroblasts (MDS-RS) that does not require blood transfusions is not 
FDA approved or listed in the Medicare approved sources. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 luspatercept-aamt. Our reviewer says 
that the service is not medically necessary. Our physician reviewer says that the requested use of luspatercept-
aamt is not Food and Drug Administration-approved for the enrollee's diagnosis and is not supported by one of 
the major drug compendia or by a CMS-approved medical journal. The use of luspatercept-aamt in this case 
does not meet Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of luspatercept-aamt have not been met. Therefore, we decided that the Plan does 
not have to pre-approve luspatercept-aamt.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do 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 and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on 
September 18, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were provided 
services, but you were not transported to the hospital. 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 18, 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 18, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services received on July 27, 2023. 
 
You asked the Plan to pay for the hospital services. You say that your diagnosis for the claim is not related to 
your hospice condition. 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.  
 You were 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 the hospital services received on July 27, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes 73564, 73501 and 71101 received on 
July 27, 2023. 
 
You asked the Plan to pay for the procedure codes 73564, 73501 and 71101. You say that the services received 
were not related to your hospice condition. 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.  You were 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 the procedure codes 73564, 73501 and 71101 received on July 
27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on March 21, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you were transported by the ambulance. The Plan denied your request. The Plan says without transport from 
the unlisted ambulance service there are no payable services.  
 
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 March 21, 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 the ambulance response and treatment without 
transport services received on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to approve an out-of-network podiatry office visit. 
 
You asked the Plan to approve the office visit. You say that this is a long-time patient that wants continuum of 
care. The Plan denied your request. The Plan says there are no extenuating circumstances making it medically 
necessary to obtain the service out-of-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 approve the office visit. Our reviewer says that the 
enrollee does not meet the criteria for coverage. Our physician reviewer found this enrollee is not currently 
receiving any active treatment and/or medical management of his/her condition that makes it medically 
necessary for this enrollee to continue care with the out-of-network podiatry provider as requested. There is not 
anything unique about this enrollees condition that would make it medically necessary for her to continue care 
with the out-of-network provider requested. The plan has shown that they have in-network podiatry specialists 
who have the qualifications and expertise necessary to meet the current medical Standards of Care required for 
treatment of the enrollees condition. The enrollees medical management and/or follow-up care be safely 
transitioned to an in-network podiatry specialist 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 office visit have not been met. Therefore, we decided that the Plan does not 
have to approve an out-of-network podiatry office visit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
11, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you want to appeal the 
amount being charged. 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 $90 
copayment for ambulance services. 
 
You have been asked to pay a $90 copayment for the ambulance services. This item/service falls within the ambulance 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 waive the copayment for the ambulance 
services provided on June 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 15, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you never went to the scheduled 
appointment. 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 $25 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $25 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on June 15, 2023.