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 need rehab to get functional skills back. The 
Plan denied your request. The Plan says that the services do not meet 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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scans of the brain and cervical spine and MRI of the 
lumbar spine. 
 
You asked the Plan to pre-approve the CT scans and MRI. You say that you are appealing the denial. The Plan 
denied your request. The Plan says the requests for imaging are not medically necessary at this time. 
 
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 scans and MRI. Our reviewer 
says that the requests are not medically necessary. Our physician reviewer found that you fell out of bed in 
October 2022 and still have unspecified pain. Neuro exam is normal. No headache or other findings to suggest 
brain disorder. If brain abnormality was a concern MRI would be more useful. No cervical spine plain films are 
in the records. No neuro findings to suggest cervical spine pathology. Lumbar spine MRI has not been shown 
to be medically necessary. Neuro exam was normal. No plain films of the lumbar spine are in the records. The 
medical necessity of the 3 requested scans has not been shown in the submitted records. 
 
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 scans and MRI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CT scans of the brain and cervical spine and MRI of the lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography/computed tomography 
(PET/CT) scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not indicated for the staging of regional lymph nodes. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the medical notes 
do not reflect that malignancy is strongly suspected. This scan will not change the need for the already planned 
biopsy. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography/computed tomography (PET/CT) scan.
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 physician oversight, frequent 
monitoring and intervention. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided safely in another setting such as a skilled nursing facility, home with home health services or home 
with outpatient therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0675). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested item is a 
necessity for your care. The Plan denied your request. The Plan says rules for coverage for PCDs have not been 
met. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for treatment of peripheral artery disease, regardless of how they are billed on the claim. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the counseling service provided on January 17, 2022. 
 
You asked the Plan to pay for the counseling service. You say that payment was denied because proof of 
payment was not provided. You also say that it has now been provided. The Plan denied your request. The Plan 
says the provider in this case is not eligible to participate in Medicare. The Plan also says that payment cannot 
be made for services rendered by a provider that is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the counseling service provided on 
January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit (99203) provided on 
February 16, 2023. 
 
You asked the Plan to waive the cost sharing for the vision service. You say that your yearly exam is always 
covered. You say that you were advised there was a copayment applied due to the medical condition that was 
found. You also say that this is what a routine exam is for and therefore should not be responsible for a 
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 $30 copayment for Medicare covered vision care.  
 
You have been asked to pay a $30 copayment for the vision service. This service falls within the Vision Care 
benefit category. Additionally, the diagnosis code listed on the claim indicates the service rendered was 
medical in nature and not routine. 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 cost sharing for the office visit 
(99203) provided on February 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
items are not medically necessary. Our physician reviewer found that the provided records in this case do not 
document the patient has a history of problems with low blood sugar (hypoglycemia) and records from May 
2023 do not document use of insulin. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a tetanus vaccine provided on September 20, 2022. 
 
You asked the Plan to pay for tetanus vaccine. You say that this vaccine was provided due to an injury which 
makes it payable by insurance. The Plan denied your request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for this vaccine on the basis that it is not coverable by 
Medicare Part B. Immunizations are not covered by Medicare Part B unless they are directly related to the 
treatment of an injury or direct exposure to a disease or condition. The records submitted do show that this 
immunization was directly related to an injury. The Plan did not provide any other rationale or evidence to 
support a denial of payment for this service. Therefore, the Plan has not shown that its decision to deny 
payment for this service is correct or justified. Therefore, we decided that the Plan has to pay for a tetanus 
vaccine provided on September 20, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425, A0426) provided on April 
11, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says these services are considered inpatient transportation and 
therefore are paid to the facility where the enrollee maintained inpatient status throughout the date in question. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the record shows that the enrollee maintained 
inpatient status at one facility throughout the date in question. This means that the services at issue are 
considered patient transportation and paid to the facility. Therefore, we decided that the Plan does not have to 
pay for the ambulance services (A0425, A0426) provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on December 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81479) provided on December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 
22, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service 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 detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L4-5, L5-S1 facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is 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 facet joint injection.  Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation regarding proceeding with radiofrequency 
ablation (RFA) should the procedure be successful in reducing enrollee's pain nor any contraindications to 
proceeding with RFA. There is a clear alternate pain generator, and the physician is not going to follow 
evidence-based algorithms. The request is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bilateral L4-5, L5-S1 facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (0241U) provided on January 25, 2023. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0241U) 
provided on January 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Drugs: Hyaluronan or derivative, euflexxa, for intra-
articular injection J7323. 
 
You asked the Plan to pre-approve Hyaluronan or derivative, euflexxa, for intra-articular injection . You say 
that the enrollee needs Hyaluronan or derivative, euflexxa, for intra-articular injection. The Plan denied your 
request. The Plan says  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Hyaluronan or derivative, euflexxa, for 
intra-articular injection. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the medical records provided are insufficient to document enrollee's clinical condition such that the 
medical necessity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronan or derivative, euflexxa, for intra-articular injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Drugs: Hyaluronan or derivative, 
euflexxa, for intra-articular injection J7323.
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 inpatient rehabilitation level of 
care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an Inpatient Rehabilitation Facility. 
 
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: 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 the services are medically necessary. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on June 1, 2023. The services in question would be provided 
before the end of that month. Therefore, we decided that the Plan does not have to pre-approve skilled nursing 
facility (SNF) care.
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 to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve IRF care with an OON. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services could be provided by a network provider. 
 
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. 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 
acute inpatient rehabilitation facility (IRF) admission and services to be provided by an out-of-network (OON) 
provider.