Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45380) to be provided at an outpatient 
hospital facility. 
 
You asked the Plan to pre-approve a colonoscopy to be provided at an outpatient hospital facility. The Plan 
denied your request. The Plan says this service is not covered by Medicare or the Plan. 
 
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 a colonoscopy to be provided at an 
outpatient hospital facility. Our reviewer says that a colonoscopy to be provided at an outpatient hospital 
facility is not medically reasonable and necessary. Our physician reviewer found a colonoscopy for colorectal 
cancer screening is medically appropriate, but this does not need to be done at a specific outpatient hospital 
facility, and can be done at any endoscopy service as covered by the Health Plan.  
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 colonoscopy to be provided at an outpatient hospital facility have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy (45380) to be provided at 
an outpatient hospital facility.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyndamax capsules. 
 
You asked the Plan to pre-approve Vyndamax capsules. 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 Vyndamax capsules.   
Benefits for Vyndamax capsules 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient admission after a ventriculoperitoneal (VP) shunt 
placement. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found given the procedure and the enrollee's medical co-morbidities, an inpatient admission 
of greater than two midnights is a reasonable expectation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve inpatient admission after a ventriculoperitoneal (VP) shunt placement.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF is an acute medical facility with 
the capacity to manage the enrollee's current medical needs on your unit while the enrollee is receiving 
rehabilitation to optimize their physical function. The Plan denied your request. The Plan says the enrollee does 
not meet medical necessity criteria for admission to an IRF.  
 
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 medical record supports 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and 
would benefit from an LTACH setting until they are able to return to their baseline and discharge home. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for admission to an 
LTACH.  
 
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 that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 the enrollee's needs will be best met at an IRF, and 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for admission to an acute 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the scaroplasty procedure. 
 
You asked the Plan to pre-approve the procedure. You say that you know the procedure cannot guarantee pain 
free results, however it is your last chance to avoid opioid dependency. The Plan denied your request. The Plan 
says that the sacral percutaneous vertebral augmentation 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 the procedure. Our reviewer says that 
the sacroplasty is medically necessary. Our physician reviewer found that this technique is supported by 
evidence based systematic review. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve the scaroplasty procedure.  
 
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 waive the copayment for the cataract surgery provided March 16, 
2023. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you did not have to pay for 
previous surgeries. 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 $325 
copayment for in-network outpatient surgery.  
 
You have been asked to pay a $325 copayment for the cataract surgery. This item/service falls within the in-
network outpatient surgery 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 cataract 
surgery provided March 16, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing code 81546 billed for date of service March 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that the analysis helps avoid diagnostic surgery. The 
Plan denied your request. The Plan says that there are no signs concerning thyroid cancer. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the services by a contract provider. The file does not show that the plan provided 
notice that the billed services would not be covered. Under Medicare rules, this means the billed services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the lab testing code 81546 
billed for date of service March 8, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on January 25, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received by an out-of-
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telehealth visit provided on January 25, 2023, 
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes for a transcutaneous electrical nerve stimulator 
(TENS) for date of service December 4, 2022. 
 
You asked the Plan to pay for the electrodes. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the items rendered are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy for Chronic Low Back Pain 
(CLBP) will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Review of the file shows that the electrodes were for a TENS unit. 
The enrollee has a diagnosis of chronic low back pain. The TENS unit and related supplies are not covered for 
this diagnosis. Based on this information, we decided that Medicare rules for coverage of the electrodes have 
not been met. Therefore, we decided that the Plan does not have to pay for the electrodes for a transcutaneous 
electrical nerve stimulator (TENS) for date of service December 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs). 
 You asked the Plan to pre-approve RFAs. You say that the enrollee has not been responsive to conservative 
care. The Plan denied your request. The Plan says the record shows the enrollee has not had 2 medial branch 
blocks at the requested levels with more than 80% sustained pain relief. 
 
The Plan follows Medicare rule. Medicare rule state that RFAs are considered medically reasonable and 
necessary for patients who have had at least 2 medically reasonable and necessary medial branch blocks with 
each providing at least 80% sustained pain relief. 
 
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 RFAs. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found the enrollee has not had 2 sets 
of diagnostic medial branch blocks (MBBs). Therefore, this is deemed 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 RFAs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablations (RFAs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on December 20, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that that you do not agree with the billed amount. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare-covered prosthetic devices, supplies related to prosthetic devices, and 
orthotics. You have been asked to pay a total of $181.53 for foot orthotics.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
December 20, 2022 Ankle foot orthosis $342.51 20% $68.50 
December 20, 2022 Pre-tibial shell 
molded 
$374.51 20% $74.90 
December 20, 2022 Rocker bottom $71.36 20% $14.27 
December 20, 2022 Foot, insert, 
removable 
$119.32 20% $23.86 
 
TOTAL:    $181.53 
 
These items fall within the prosthetic devices and related 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 pay for foot orthotics provided on December 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the sleep study services received from 
October 25, 2022, to October 26, 2022. 
 
You asked the Plan to waive the coinsurance for the sleep study services. You say that you feel these services 
should be covered with the doctor and the 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 40% 
coinsurance for a home based sleep study.  
 
 You have been asked to pay 40% coinsurance for the sleep study services. This 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 coinsurance for the sleep study services received from October 25, 2022, to October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 16, 2023, to March 16, 
2023. 
 
You asked the Plan to pay for a home visit. You say that you believed prior authorization was not needed for 
the service. 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 
February 16, 2023, to March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for layer closure, wounds scalp/axillae/trunk/extremities 
provided on February 16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for layer closure, wounds scalp/axillae/trunk/extremities with an out-of-network 
provider. You say that the services were necessary. The Plan denied your request. The Plan says you received 
service from a provider who does not participate in Medicare for non-emergent services and were not referred 
to these providers by a contracted 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for layer closure, wounds 
scalp/axillae/trunk/extremities provided on February 16, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel. 
 
You asked the Plan to pre-approve Enbrel. You say that that the enrollee has tried methotrexate and did not 
tolerate it. The Plan denied your request. The Plan says that self-administered drugs does not fall under 
Medicare Part B coverage. 
 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 Enbrel.