Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for each inpatient hospital stay provided from 
October 12, 2022, to December 17, 2022. 
 
You asked the Plan to waive the copayments for each inpatient hospital stay. You say that you want to appeal 
these copayments. 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 $335 
copayment per day for days 1-6 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment per day for any additional days of the same in-network inpatient hospital stay. 
 
You have been asked to pay a $335 copayment per day for days 1-2 of the inpatient hospital stay provided from 
October 12, 2022, to October 15, 2022. You have been asked to pay a total of $670 for this inpatient hospital 
stay ($335 copayment per day x 2 days = $670). You have also been asked to pay a $335 copayment per day 
for days 1-3 for the inpatient hospital stay provided from December 14, 2022, to December 17, 2022. You have 
been asked to pay a total of $1,005 for this inpatient hospital stay ($335 copayment per day x 3 days = $1,005). 
This item/service falls within the inpatient hospital 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 copayments for each inpatient hospital stay provided from October 12, 2022, to December 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0990, E1002, E2361, E1028, E0955, and E2607). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the medical need for a power mobility device with power tilt was documented, reviewed by the 
enrollee's attending physician, and agreed upon that the need is required. The Plan denied your request. The 
Plan says the enrollee does not have a medical need for single power options included with group 3 power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair (PWC) with single 
power option (such as code K0856) is covered if the criteria listed in the Medicare rules section of this letter 
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 a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, and does not have spasticity impacting positioning requiring an alternative means of managing 
power drives. Our reviewer also found that the enrollee has adequate upper body strength to manage standard 
power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0990, E1002, 
E2361, E1028, E0955, and E2607).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) skilled nursing visits, 5 physical therapy visits, 
and 4 occupational therapy visits, (G0299, G0151, G0152). 
 You asked the Plan to pre-approve additional home health services. You say that you disagree with the denial 
and request reconsideration. 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 additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled nursing services or skilled rehab 
services to provide treatment that is medically necessary. The enrollee does not require additional skilled 
nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the 
enrollees condition, perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve five (5) skilled nursing visits, 5 physical therapy visits, and 4 
occupational therapy visits, (G0299, G0151, G0152).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that your provider ordered the prostate-specific 
membrane antigen (PSMA) PET scan to find out if you have any cancer in your prostate. The Plan denied your 
request. The Plan says this test is not covered for an initial evaluation of prostate cancer. 
 
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 a PET/CT scan. Our reviewer says that 
a PET scan for prostate cancer is covered for initial staging and recurrent restaging of proven prostate cancers 
not with elevated prostate-specific antigens (PSAs). Our physician reviewer found Magnetic Resonance 
Imaging (MRI) and biopsy for prostate cancer diagnosis is needed prior to staging. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical localization imaging (78815).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration based on the 
records submitted. The Plan denied your request. The Plan says admission to an IRF is not medically 
necessary.  
 
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 enrollees 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. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee continues to require a 
multidisciplinary team for physician assessment and intervention. The Plan denied your request. The Plan says 
the enrollee can receive the services needed in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was intubated and ventilated, and subsequently received a tracheotomy 
and feeding tube. The enrollee is being actively managed for infections, renal failure and encephalopathy. 
There is no evidence that the enrollee requires services that are not currently available. It does not appear that 
weaning and decannulation are currently appropriate. The enrollee can remain at the current facility until no 
acute services are required. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraosseous nerve ablation. 
 
You asked the Plan to pre-approve an intraosseous nerve ablation. You say that the member has tried and failed 
conservative treatment without relief.  The Plan denied your request. The Plan says this procedure is not 
covered. 
 
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 an intraosseous nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental 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 an intraosseous nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an intraosseous nerve ablation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your providers are recommending IRF services, and 
you are appealing the denial. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
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 the role of genicular RFA is the subject 
of ongoing clinical trials and is considered experimental/investigational at this time. The services are therefore 
not reasonable or medically necessary for the enrollee. 
 
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 genicular radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
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 Orthovisc is covered when specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right knee 
osteoarthritis. The records do not document a trial and failure of conservative pharmacologic and non-
pharmacologic therapy over a three-month period. The criteria for coverage are not met and the requested 
Orthovisc is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orthovisc.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk without assistance and 
require IRF services to regain your prior level of functioning. The Plan denied your request. The Plan says that 
the request is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for physical 
and occupational therapy. Additionally, there a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclophosphamide and Darzalex Faspro with Xgeva 
and Dexamethasone. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of relapsed 
multiple myeloma. The Food and Drug Administration (FDA) has not stated that the requested drugs are indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive 
citation for the use of the requested drugs in the enrollee's specific clinical situation. No literature from a 
Medicare-approved cancer journal was submitted. The requested drugs are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Cyclophosphamide and Darzalex Faspro with Xgeva and Dexamethasone.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services related to end-stage renal disease (ESRD) 
provided on August 4, 2022, to August 30, 2022. 
 
You asked the Plan to pay for the ESRD-related services. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD services are not separately 
payable. These services 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 services related to end-stage renal 
disease (ESRD) provided on August 4, 2022, to August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost Glucose Control (B4154).  
 
You asked the Plan to pre-approve the Boost Glucose Control. You say that the enrollee has difficulty eating 
solid foods due to having no teeth. It is difficult to feed the enrollee and the enrollee has been losing weight. 
The Plan denied your request. The Plan says oral supplements are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Boost Glucose Control (B4154).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the disposable liner/shield/guard/pad/undergarment, for 
incontinence, each (T4535). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee uses 8 to 10 pads daily for 
bladder incontinence issues secondary to health conditions and requires constant support for changing. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the disposable 
liner/shield/guard/pad/undergarment, for incontinence, each (T4535).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy procedure provided on 
February 13, 2023. 
 
You asked the Plan to waive the copayment for an endoscopy procedure. You say that you were quoted a $40 
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 $270 
copayment per day, outpatient procedures and services, including, but not limited to, diagnostic and therapeutic 
endoscopy, and outpatient surgery performed in an outpatient hospital.  
 
 You have been asked to pay a $270 copayment for an endoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 endoscopy procedure provided on February 13, 2023.