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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 10, 2019 to 
September 11, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the enrollee could have been treated at a lower level of care. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found this elderly patient presented with evidence of urinary tract infections (UTI) and possible 
pyelonepnritis with leukocytosis, hypoxemia, and evidence of UTI.  At that point it was reasonable to expect 
that patient would require 2 or more midnights with risk of impending sepsis. 
 
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 pay for the acute inpatient hospital care provided from September 10, 2019 to September 11, 2019.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper endoscopy rendered on October 10, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 43239 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 43242 and 43239. Code 43239 is a column II code with a 
modifier indicator of 1 when billed with column I code 43242. Code 43239 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the upper 
endoscopy rendered on October 10, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for advanced imaging services provided on November 
28, 2018. 
 
You asked the Plan to waive the copayment for advanced imaging services. You say that you are appealing 
your cost-share responsibility for the services you received. The Plan denied your request. The Plan says that 
the claim was processed accordingly with your 2018 EOC benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It appears that the plan?s contracted delegate has failed to forward the 
appropriate evidence of coverage to support the cost-share for the advanced imaging services provided on 
November 28, 2018. Therefore, we decided that the Plan has to waive the copayment for advanced imaging 
services provided on November 28, 2018.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
March 17, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the enrollee requires the device. The Plan denied your 
request. The Plan says the documentation submitted did not include a Signed and Dated Physician's Order to 
indicate the specific supplies for the billed date of service; therefore, the billed supply code cannot be 
supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The physician order 
is not signed or dated; therefore the code cannot be verified. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on March 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00402) provided on January 28, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
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 00402 is "Anesthesia for procedures on the 
integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, 
reduction or augmentation mammoplasty, muscle flaps)". 
 
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 code 00402 is not supported by the records provided. Our coding reviewer found that the medical records 
provided indicated total anesthesia time was 8 hours 9 minutes. This does not equate to 500 units of anesthesia 
time, therefore this service cannot be verified. 
 
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 anesthesia services (00402) provided on January 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopy (43246) provided on February 27, 2020. 
 
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration because the 
services were ordered by an in-network surgeon at an in-network facility. The Plan denied your request. The 
Plan says the surgeon did not document medical necessity for additional payment for an assistant during this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for CPT code 43246. The 
Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.  

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 pay for the laparoscopy. Our reviewer says that the 
documentation does not support that this part of the procedure was complicated. Our physician reviewer found 
the medical necessity for an assistant for placement of the PEG tube is not demonstrated. 
 
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 laparoscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for a laparoscopy (43246) provided on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care from December 1, 2019 through 
December 19, 2019. 
 
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
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 SNF care from December 1, 2019 through December 19, 2019. You 
were asked to pay a $142 copayment per day for days Days 21 - 100: $142 for SNF care. However, you are 
only asked to pay a $1,308.55 for the SNF care because you reached your maximum out-of-pocket on this 
claim. 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 SNF care from December 1, 2019 through 
December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) provided on March 
20, 2020. 
 
You asked the Plan to pay for the TTE. You say that you feel that this should be covered as it was 
recommended by two doctors. The Plan denied your request. The Plan says this testing was provided as part of 
pilot licensing and was required by the FAA. Medicare does not pay for exams which are required by third 
parties. 
 
The Plan must follow Medicare rules. Medicare rules say that exams that are required by third parties are 
excluded from coverage. Therefore, we decided that the Plan does not have to pay for the transthoracic 
echocardiogram (TTE) provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 10, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because this trial 
helped you avoid doing a stem cell transplant and it was only available at this location. The Plan denied your 
request. The Plan says visits that are part of a Medicare qualified clinical study should be billed to regular 
Medicare first. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services.
 
In this case, you asked the Plan to pay for the office visit as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pay 
for the office visit provided on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the TECENTRIQ injection provided on April 3, 2020. 
 
You asked the Plan to pre-approve the TECENTRIQ injection. You say that this was a medically necessary 
treatment. The Plan denied your request. The Plan says there is no support for the treatment in the literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the TECENTRIQ injection. Our 
reviewer says that the requested use of this medication is not considered reasonable and necessary. Our 
physician reviewer found the enrollee is a 76-year-old woman with a diagnosis of right vulvar carcinoma which 
was treated with surgery and post-operative radiation. A biopsy on 7/17/19 showed recurrent vulvar cancer. 
There is no support found in the compendia for use of TECENTRIQ for the treatment of the enrollee's 
recurrent carcinoma of the vulva. 
 
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 TECENTRIQ injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the TECENTRIQ injection provided on April 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam, first intraoral periapical x-ray, three 
additional intraoral periapical x-rays, prophylaxis, and resin-based composite provided from February 6, 2020 
to February 21, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral exam, intraoral periapical x-rays, prophylaxis, and resin-based 
composite. You say that this dentist was listed as an in-network provider with your plan. The Plan denied your 
request. The Plan says the treating provider is OON. The Plan also says that there are no calls on file from you 
contacting the Plan for the contract status of the provider prior to the services being rendered. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral exam, first intraoral periapical x-ray, three additional intraoral periapical x-rays, prophylaxis, and resin-
based composite provided from February 6, 2020 to February 21, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care from February 1, 2019 through 
March 10, 2019. 
 
You asked the Plan to waive the copayment for SNF care. You say that no one told you about the copayment. 
The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 
benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Per your plan benefits, there is a $0 copayment each day for days 1 to 20. $160 copayment each day for days 
21 to 51. $0 copayment for additional Medicare-covered days, up to 100 days. You received SNF care from 
January 21, 2019 through to March 10, 2019. Days 1 ? 20 are from January 21, 2019 through to February 9, 
2019. Days 21 to 49 are from February 10th through to March 9, 2019. Claim for dates of service February 1 to 
February 28, 2019 has 19 days of cost share equaling $3,040. Claim for date of service March 01 to March 10, 
2019 has cost share of $100 only as your out of pocket maximum was met for the year of 2019. 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 SNF care from February 1, 2019 through March 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder test provided on November 21, 2019. 
 
You asked the Plan to pay for the test. The Plan denied your request. The Plan says this is not a covered 
service. 
 
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 pay for the test. Our reviewer says that the requested 
services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 
CxBladder is not a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper 
tract imaging will still be necessary regardless of the results of CxBladder testing. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pay for the CxBladder test provided on November 21, 2019.
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 the member can receive physical therapy and occupational therapy in a 
less intensive 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on March 10, 
2020. 
 
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says this 
service is not covered. The Plan also says that you did not elect to purchase a supplemental dental benefit 
package. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2391) provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 Sensor. You say that the requested sensor is medically 
necessary. The Plan denied your request. The Plan says there was no medical information submitted showing 
that the enrollee has been checking blood sugar levels at least 4 times per day. The Plan says that there is no 
documentation showing that the enrollee takes insulin at least 3 times per day and that the dose needs frequent 
adjustment, due to blood sugar readings. The Plan says that there is no documentation showing that the enrollee 
has seen the prescribing physician within the last 6 months to evaluate diabetes control. The Plan says that 
there is no documentation of a plan to evaluate the enrollee every 6 months, should a CGM get approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered for 
certain indications. Medicare rules also say that information must be submitted to confirm that Medicare 
coverage criteria have been met.  
 
We looked at the file and Medicare rules. The case file did not include medical records. The case file shows 
that the Plan sent notification that this medical documentation was needed. Without medical records, we cannot 
make a determination regarding medical necessity and you have not proven that Medicare coverage criteria for 
CGM supplies have been met. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had two diagnostic blocks that have provided over 80% relief. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency neurotomy is only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She has multiple pain generators, such as disc 
herniation, spinal stenosis at L3-L4 and L4-L5, as well as facet arthropathy. She has failed physical therapy in 
the past. She had 2 diagnostic MBBs. The first produced only 70% pain relief. Coverage rules require that each 
diagnostic block produce 80% or greater pain relief. Therefore, the requested is not considered medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation (RFA).