Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for a Meditronic 670G continuous glucose
monitor.
You asked the Plan to pre-approve continuous glucose monitor. You say that you need this for the dispensing
of your insulin medications. The Plan denied your request. The Plan says the denial of authorization for these
items is correct, because this glucose monitor is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered by
Medicare if they meet certain criteria, including being approved for use in place of a blood glucose monitor for
making diabetes treatment decisions.
We looked at the file and Medicare rules. The Meditronic 670G monitor is not intended to replace a blood
glucose monitor for making diabetes treatment decisions, therefore it is considered to be a non-therapeutic
continuous glucose monitor which is not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the
Plan does not have to pre-approve sensors for a Meditronic 670G continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can be treated in a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. The enrollee is not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection, expandable controller and 
harness for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary for the 
enrollee. The Plan denied your request. The Plan says that there is not a medical need to control these power 
options through the joystick. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Documentation 
shows that the patient has 3/5 strength in both upper extremities and is independent with feeding and meal prep 
with strength and function that should be adequate for the patient to be able to control the power options using 
their own switches. Our physician reviewer found that these items are not medically reasonable and necessary 
for the enrollee in this case. 
 
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 items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection, expandable controller and harness for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient services following a hip surgery, for the enrollee.
You asked the Plan to pre-approve inpatient services. You say that you have concern for the enrollee needing inpatient services. The Plan denied your request. The Plan says the hip surgery is approved as an outpatient (observation status) and inpatient admission is not approved.
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. This procedure is typically done as outpatient. The Plan has approved outpatient care. If there is a complication during or after surgery, the enrollee's hospital stay can be changed to inpatient status with proper documentation supporting the change. Therefore, we decided that the Plan does not have to pre-approve inpatient services following a hip surgery, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental surgery and the repair of tooth sockets in an operating 
room. 
 
You asked the Plan to pre-approve the dental surgery and the repair of tooth sockets in an operating room. You 
say that the enrollee has a complex cardiac history that will limit the use of local anesthesia with epinephrine. 
You say that this limitation, in conjunction with the extent of the procedure, makes the enrollee a poor 
candidate for extraction in an outpatient clinic. You say that the requested services are medically necessary and 
need to be performed in an operating room. You say that the enrollee can then receive follow-up care in the 
clinic. The Plan denied your request. The Plan says that the requested services are not covered. 
 
The Plan must follow Medicare rules. Medicare generally does not cover dental services. However, the Plan 
offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers dental extractions and oral surgery services are covered when the services are medically 
necessary and reasonable. 
 
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 dental surgery and the repair of 
tooth sockets in an operating room. Our reviewer says that the requested services are considered medically 
reasonable and necessary in this case. Our physician reviewer found a review of the enrollee's medical and 
dental records and radiographs indicates that the enrollee is in need of multiple extractions.  
 
The treating oral surgeon recommends the procedure be done in a hospital setting due to the enrollee's medical 
history and in regard to the extent of the procedure which would involve an excessive amount of local 
anesthesia. It would be in the enrollee's best interest, and medically reasonable to have the procedure done in a 
hospital setting where monitoring could more easily be accomplished during the procedure and during 
recovery. 
 
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 dental surgery and the repair of tooth sockets in an operating room have 
been met. Therefore, we decided that the Plan has to pre-approve dental surgery and the repair of tooth sockets 
in an operating room.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show heart symptoms noted by the doctor. 
 
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 imaging. Our reviewer says that the 
requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has very atypical chest pain that does not have anginal features. There is an 
electrocardiogram that is interpretable and does not show any acute ischemic changes. In this circumstance 
further evaluation with stress testing is debatably medically necessary. If stress testing were thought to be 
medically necessary, then standard exercise electrocardiography should be sufficient. Coverage criteria for 
nuclear stress testing is not met since there are no documented covered indications for the procedure. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee could suffer harm if health services are 
not rendered quickly. The Plan denied your request. The Plan says care can be received at a skilled nursing 
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 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 that given the enrollee's current functional level, IRF level of therapies is not 
required. Our reviewer says that the enrollee's rehab needs can be met in a lower intensity setting. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for destruction by neurolytic agent (64636) provided on 
November 7, 2019. 
 
You asked the Plan to pay for the destruction by neurolytic agent. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 
not support the units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the destruction by neurolytic agent. Our reviewer says that 
CPT code 64636 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
procedure report documents facet injections were performed at L5 - S3 levels, which supports 2 additional 
units.  Therefore, billing 3 additional units cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the destruction by neurolytic agent have not been met. Therefore, we decided 
that the Plan does not have to pay for destruction by neurolytic agent (64636) provided on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary and were 
covered in the past. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of a nephrostomy tube (50389) provided on 
February 6, 2020. 
 
You asked the Plan to pay for the tube removal. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 50389 is removal of nephrostomy tube, requiring 
fluoroscopic guidance (eg, with concurrent indwelling ureteral stent). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the tube removal. Our reviewer says that CPT code 50389 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report did 
not include documentation of removal of nephrostomy tube.  Operative report documents that nephrostomy 
tube was noted coming in from the posterior aspect of the quadratus lumborum. It was divided with heavy 
scissors. Therefore, this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the tube removal have not been met. Therefore, we decided that the Plan does 
not have to pay for the removal of a nephrostomy tube (50389) provided on February 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on April 26, 2019 billed 
with codes 99601 and 99602. 
 
You asked the Plan to pay for the home infusion services. You say that these services should be paid. The Plan 
denied your request. The Plan says the services were billed with codes that are not valid for Medicare billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the codes billed in this case have a status indicator of "I" in the Physician Fee Schedule meaning 
that they are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules 
for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home infusion services provided on April 26, 2019 billed with codes 99601 and 99602.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the 
enrollee on January 13, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that lab testing 
generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific 
medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. 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 drug testing services 
(HCPCS G0482) provided to the enrollee on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the 
enrollee on September 9, 2019. 
 
You asked the plan to pay for this service. You say that this claim should be paid. The plan denied your 
request. The plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. This equipment was used during and after a surgical procedure by the facility. This equipment did 
not go home with the enrollee. Payment for this service would have been included under the facility claim. 
Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the 
Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or 
without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on September 
9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge day management services provided on December 20, 2019.
You asked the Plan to pay for the discharge management services. You say that these services should be paid. The Plan denied your request. The Plan says payment was approved for the inpatient visits other than the discharge management as no progress note for that date of service was provided.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. In this case, there is no discharge summary note for December 20, 2019. Without documentation of the services provided on this date, the billing of this code is not supported. Therefore, we decided that the Plan does not have to pay for the discharge day management services provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 16, 
2019. 
 
You asked the Plan to pay for home infusion therapy. You say that this code has been paid in the past. The Plan 
denied your request. The Plan says this code is not payable under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on 
January 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam with fundus photography (CPT 
Code 92250) on June 8, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic testing. You say that this service should be 
included in your $40 copayment. The Plan denied your request. The Plan says the claim payment for date of 
service February 25, 2020 was a one-time approval based on your particular circumstances: your laboratory test 
was billed to your plan as diagnostic test and not a routine test and you were not aware about. The Plan states 
they will process future claims according to the terms of your plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the diagnostic testing on June 8, 2020. You are asked to pay a $10 
copayment for the diagnostic testing. Your EOC states that enrollees must pay a $10 copayment for x-rays, 
laboratory and other diagnostic tests for each category per service date (this copayment does not apply to 
interpretation costs). 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 eye exam with fundus 
photography (CPT Code 92250) on June 8, 2020.