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

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer (22869). 
 
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Superion interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the spacer remains experimental. More research is needed to show the 
safety and efficacy of the device. It is not needed in this case. There is no spinal instability documented. 
 
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 Superion interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Superion interspinous spacer (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 he complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
from 6/14/2020-6/18/2020 for CVA. He was transferred to inpatient rehabilitation facility from 6/19/2020-
7/11/2020 then discharged home with home health services. There are no new medical problems and 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. The medical record supports a need for physical and occupational therapy but it does not 
support a need for an intensive rehabilitation therapy program. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary, as you have essential 
tremors and cannot hold the needle steady on the current monitor. The Plan denied your request. The Plan says 
the records reflect that you are not currently insulin-treated with three or more daily injections of insulin or 
using a Medicare-covered continuous subcutaneous insulin infusion pump. 
 
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 the monitor. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found given that you are not currently on insulin, and do not require frequent insulin adjustment, you do not 
meet the criteria for this monitor. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on January 29, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you disagree with this decision. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization is required. The Plan says that the member's primary care physician did not refer these services. 
 
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 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 lab tests provided on January 29, 2020 by an out 
of network (OON) provider.
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 a CGM. You say that you do not want to use your old monitor because it 
causes pain in your hand. The Plan denied your request. The Plan says that you do not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
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 requires pulmonary 
management, telemetry, and nutritional management. The Plan denied your request. The Plan says the enrollee 
can continue care at the current facility. 
 
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 physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include respiratory support with ventilator weaning and tracheostomy care, surveillance laboratory 
studies, tube feeding, and therapy services. The documentation does not support that the enrollee in this case 
requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 
care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate 
for the diagnosis and condition of the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on June 12, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for wound care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's 
primary care physician did not refer these services. 
 
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 has network providers 
available who can provide 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 wound care provided on June 12, 2020 by an out 
of network (OON) provider.
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 clinical information provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the records do not show that it 
is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital. 
 
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 it appears the enrollee is improving but requires additional short-term acute care 
services until more stable. The enrollee does not require services at an LTACH which are not already available 
at the current facility. There are no services at the LTACH that the enrollee requires that are not available at the 
current facility. The enrollee does not appear to require more than 24 days of acute care services. Continued 
care at the current setting is appropriate and transfer to a lower level of care may be considered in the near 
future once more stable. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ondansetron and Meclizine Hydrochloride provided on 
May 11, 2020. 
 
You asked the Plan to pay for the Ondansetron and Meclizine Hydrochloride. You say that you were prescribed 
Ondansetron for nausea while you were in the emergency room. The Plan denied your request. The Plan says 
these drugs are self-administered, and are not covered by Medicare Part B. 
 
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 pay for the Ondansetron and Meclizine 
Hydrochloride provided on May 11, 2020.  
 
Benefits for the Ondansetron and Meclizine Hydrochloride 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 pre-approve genicular nerve ablation of the knee. 
 
You asked the Plan to pre-approve the genicular nerve ablation. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says the requested 
procedure is considered investigational. 
 
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 the genicular nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no higher quality studies demonstrating long-term efficacy and 
possible adverse effects. 
 
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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular nerve ablation of the knee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 52232) provided on August 1, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
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 52232 is "Cystourethroscopy, with insertion of 
indwelling ureteral stent (eg, Gibbons or double-J type)". 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of CPT code 52232 is not supported by the records provided. Our coding reviewer found that the medical 
records provided does have documentation that a bilateral stent placement was performed, however, the 
medical records submitted are noted as an addendum. Without original medical records to compare to, it is 
unclear what was altered in the medical record, therefore CPT 52332 is not eligible for reimbursement because 
guidelines for an addendum have not been met. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 52232) provided on August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for continuous positive airway machine 
(CPAP) supplies you received on May 18, 2020. 
 
You asked the Plan to waive the deductible for the CPAP supplies. You say that you want to be reimbursed for 
this expense. The Plan denied your request. The Plan says you had not yet met your deductible at the time you 
received these supplies, so you were charged this amount correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible for items and services received in-network, including 
durable medical equipment and supplies. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for in-
network items and services. This cost sharing is a contractual obligation that had not been met at the time the 
C-PAP supplies was received on May 18, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for continuous positive airway machine (CPAP) supplies you received on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 12, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary genetic screening testing provided on January 17, 
2020. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because molecular genetic hereditary 
predictive screening testing is not a Medicare benefit for the diagnoses listed and these tests were done for 
screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover 
these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
hereditary genetic screening testing provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on April 28, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you have the passport which covers 
services for you when you are in Arizona. Other provider claims have been paid with no issues in Arizona and 
you do not know why this claim was denied. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 has network providers 
available who can provide 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 outpatient office visit (99213) provided on 
April 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Aflibercept injection (J0178) received 
on April 28, 2020. 
 
You asked the Plan to waive the coinsurance for an Aflibercept injection. You say that copayments for primary 
care providers and specialists are being waived due to COVID-19. The Plan denied your request. The Plan says 
the correct coinsurance was applied. 
 
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 each Medicare-covered Part B drug. The Plan has waived cost-sharing for primary care 
provider and specialist provider visits effective from May 11 to September 30, 2020. 
 
You have been asked to pay $756.02, or 20% coinsurance of the Plan-allowed amount of $3,780.12, for an 
Aflibercept injection. An Aflibercept injection falls within the "Medicare Part B Prescription Drugs" benefit 
category. The date of service is prior to the effective date of the Plan?s cost-sharing waiver. 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 an Aflibercept injection (J0178) received on April 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D rendering with interpretation and reporting services 
coded 76376 provided on February 28, 2020. 
 
You asked the Plan to pay for the 3D rendering with interpretation and reporting services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not separately payable. 
 
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, we have confirmed that code 76376 
for the 3D rendering with interpretation and reporting services has a bundled relationship with code 73700 and 
cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the 
3D rendering with interpretation and reporting services coded 76376 provided on February 28, 2020.