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

 
We decided that the Plan does not have to provide a therapeutic continuous glucose monitor. 
 
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that because of a medical 
condition of your left hand you need a CGM. The Plan denied your request. The Plan says criteria is not met 
for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we 
decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee underwent knee 
surgery on October 21, 2020, and is now at home with pain in weakness and legs. The IRF screen on January 
14, 2021, states she needs varied assistance with bathing, eating, toilet hygiene, dressing, and bed mobility. She 
does not require the intensity of services in an IRF. Specifically, the enrollee is not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 needs provision of care in a 
LTACH. The Plan denied your request. The Plan says the enrollee is not medically stable and needs to stay in 
the 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care There is no documentation provided necessitating admission 
to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at 
the present acute care hospital. The enrollee does not require services at the LTACH that are not available at 
the acute care hospital where he is currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this circumstance, therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy. Therefore, the efficacy of the CardioMEMS device is 
uncertain at this time according to leading authorities and not recommended in current guidelines for the 
treatment of heart failure. Medicare coverage criteria are not met, since the device should still be considered 
experimental/investigational. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the CT scan and physical therapy 
evaluation provided during outpatient services provided from August 19, 2020, to August 21, 2020 
 
You asked the Plan to waive the copayments for the CT scan and physical therapy evaluation. You say that you 
were inpatient and these services should be covered. The Plan denied your request. The Plan says you were 
charged these copayments 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 $250 
copayment for Outpatient Hospital Advanced Imaging Services and a $25 copayment for Outpatient 
Rehabilitation Services.  
 
You have been asked to pay a $250 copayment for Outpatient Hospital Advanced Imaging Services and a $25 
copayment for Outpatient Rehabilitation Services. 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 
the CT scan and physical therapy evaluation provided during outpatient services provided from August 19, 
2020, to August 21, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (A9276 and A9277). 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says these "A" codes that were requested are never covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that A9276 and A9277 are never covered by 
Medicare. 
 
The requested monitor was requested with A9276 and A9277. 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 (A9276 and A9277).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 73630) provided to the enrollee on 
July 24, 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 this is listed with a bilateral indicator of "3" which means the usual payment adjustment for 
bilateral procedures does not apply. 
 
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 73630 is "radiologic examination, foot." 
 
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 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation did not include a modifier to indicate which foot service was performed. Per the provider 
"medical records don't indicated which side it was done on modifier can?t be added". Modifiers LT and RT 
provide supplemental information for procedures performed on paired structures.  These modifiers don't 
directly affect payment, but provide vital information to identify the location for service.  In this case, 
clarification should be made as to which side service was performed, before billing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services (CPT 73630) provided to the enrollee on July 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in the hospital and are ready to move to IRF. 
The Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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 complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on 
February 14, 2019. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that you did not receive the 
enrollee's benefit determination in time. The Plan denied your request. The Plan says this was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a psychiatric diagnostic evaluation was not filed until September 2, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) 
provided on February 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on March 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a duplex scan. You say that you would like this claim reprocessed and approved 
for payment. 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 a duplex scan provided on March 5, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hyaluronan intra-articular injection services coded J7322 
provided on June 25, 2020. 
 
You asked the Plan to pay for the Hyaluronan intra-articular injection 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 
supported by the documentation. 
 
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 J7322 is Hyaluronan or derivative, HYMOVIS, for intra-
articular injection, 1 mg. 
 
We find that CPT code J7322 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of the dosage administered of Hyaluronan or derivative, HYMOVIS, for 
intraarticular injection 24mg; therefore, code J7322 cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of the Hyaluronan intra-articular injection services have not been met. 
Therefore, we decided that the Plan does not have to pay for the Hyaluronan intra-articular injection services 
coded J7322 provided on June 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography Angiography (CTA) of the 
heart. 
 
You asked the Plan to pre-approve CTA scan. You say that the enrollee was told that an appeal would be 
approved. The Plan denied your request. The Plan says the denial of authorization for this testing is correct 
because the records do not show that the enrollee has a covered indication for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that CTA scans are not covered for screening. 
 
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 CTA scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested CTA scan. Our physician reviewer found this 
request is considered screening in the absence of any cardiac or pulmonary symptoms and is therefore non-
covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTA scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Computed Tomography Angiography (CTA) of the heart.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your care can safely be given in subacute care facility such as 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. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
be able to perform/tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. 
The enrollees care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a High Utilization amount of lancets and test strips. 
 
You asked the Plan to provide a High Utilization amount of lancets and test strips. You say that testing twice a 
day can help to control blood sugar. The Plan denied your request. The Plan says there is not enough evidence 
to support the need to test 2 times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that the quantity of test strips (code A4253) and 
lancets (code A4259) that are covered depends on the usual medical needs of the beneficiary. 
 
We looked at the file and Medicare rules. There is no physician documentation supporting the medical need for 
the requested quantity. Based on this information, we decided that Medicare rules for coverage of a High 
Utilization amount of lancets and test strips have not been met. Therefore, we decided that the Plan does not 
have to provide a High Utilization amount of lancets and test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services (17250) provided July 29, 2020. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says a corrected claim is needed. 
 
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 17250 is not supported in the medical record. Specifically, the CPT code was billed 
without an allowed primary diagnosis. Based on this information, we decided that Medicare rules for coverage 
of the wound care services have not been met. Therefore, we decided that the Plan does not have to pay for 
wound care services (17250) provided July 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioimpedance Spectroscopy. 
 
You asked the Plan to pre-approve Bioimpedance Spectroscopy. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested 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 Bioimpedance Spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of unspecified site of 
left female breast (invasive ductal carcinoma architecturally poorly differentiated, high nuclear grade, SBR 
grade III. While Bioimpedance spectroscopy may be used for the assessment of breast cancer-related 
lymphedema, the accuracy of bioimpedance spectroscopy has not been determined. Further study is needed. 
The documentation does not support that requested service is 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 Bioimpedance Spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Bioimpedance Spectroscopy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, while you do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. Finally, there is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.