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

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors. 
 
You asked the Plan to pre-approve Freestyle Libre continuous glucose monitor sensors. You say that you 
require sensors to check your blood sugar. 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 considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle 
Libre continuous glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Libre continuous glucose monitor sensors.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer (14041) provided on October 28, 
2021. 
 
You asked the Plan to pay for the adjacent tissue transfer (14041). You say that this is the code for the 
rotational flap and this does not bundle. You say that this was coded correctly, and the records support the 
billing. The Plan denied your request. The Plan says the record does not support this code. 
 
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 14041 is adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm. 
 
  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 adjacent tissue transfer (14041). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
procedure report describes undermining, creating flaps for closure. The documentation does not support 
transfer or rearrangement of adjacent tissue transfer and 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 adjacent tissue transfer (14041) have not been met. Therefore, we decided 
that the Plan does not have to pay for the adjacent tissue transfer (14041) provided on October 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from November 29, 
2021, to December 3, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the inpatient care was medically necessary. The 
Plan denied your request. The Plan says the inpatient level of care was 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 pay for the inpatient care. Our reviewer says that the 
inpatient care is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation does not indicate that the enrollee required or received any inpatient diagnostic studies or therapeutic interventions. The documentation does not indicate there was clinical rational for 
inpatient level of care services for the dates of service in this case. Therefore, the reviewer found that the 
inpatient hospital services at issue in this case were not medically reasonable or 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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient hospital care provided from November 29, 2021, to December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), 
and electronic connection (E2311). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items 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 the wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that it is medically necessary to control the wheelchair's 
power options through a joystick. Provided records document that the enrollee is independent with feeding thus 
indicating she has adequate upper extremity strength and function to operate the wheelchairs power options 
with their own switches. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), and electronic 
connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) receiver 
(K0554). 
 
You asked the Plan to pre-approve the CGM receiver. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) receiver (K0554).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on April 20, 2021. 
 
You asked the Plan to pay for the office visit. You say that several other dates of service for the same service 
were paid and the services were medically necessary. The Plan denied your request. The Plan says that the 
rendering provider must bill services under their Federal Tax Identification number. 
 
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. The claim includes a valid federal tax identification number for this provider. 
The Plan has not forwarded any evidence to support why this provider is not eligible for payment. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the office visit 
provided on April 20, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection services. 
 
You asked the Plan to pre-approve epidural steroid injection services. You say that this is medically necessary 
for your medical condition. The Plan denied your request. The Plan says the clinical records provided for 
review do not address impact of your pain on your quality of life or function. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are subject to the criteria 
listed in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injection services. Our 
reviewer says that the requested procedure is not medically reasonable and necessary based on Medicare 
coverage criteria. Our physician reviewer found that you are a 62-year-old woman with chronic neck pain that 
radiates to her shoulder and arm. You are currently doing Physical Therapy. You are not on any pain 
medications. Imaging shows multi-level degenerative disc disease, spinal stenosis at C6-C7 and foraminal 
stenosis at Left C6-C7.  
 
While the imaging shows clear pathology, there is a lack of documentation of how this is affecting your 
activities. It is also unclear why she is not taking any pain medications. At this point, the request is deemed not 
medically reasonable or 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 epidural steroid injection services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve epidural steroid injection services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
October 4, 2021, to October 29, 2021. 
 
You asked the Plan to pay for home health services. You say that the guidelines were followed. The Plan 
denied your request. The Plan says the RAP claim was files late. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not support that the RAP was submitted within 5 calendar days after the start of care. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from October 
4, 2021, to October 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that the member is at high risk of falling and it is not 
safe for him to go home. The Plan denied your request. The Plan says that the enrollee is not yet ready for 
discharge from the hospital. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on January 8, 2022. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 services (70450) provided on January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis B vaccine (90636) and administration (90472), 
and the Typhoid vaccine (90691) and administration (90471), provided on December 14, 2021. 
 
You asked the Plan to pay for the Hepatitis B vaccine and administration, and the Typhoid vaccine and 
administration. You say that the services were medically necessary. The Plan denied your request. The Plan 
says you are not at a high or intermediate risk of contracting Hepatitis B and the Typhoid vaccine is not 
covered; the administration isn't covered either. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis B 
vaccine and administration, and the Typhoid vaccine and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis B 
vaccine and administration, and the Typhoid vaccine and administration. Therefore, we decided that the Plan 
does not have to pay for the Hepatitis B vaccine (90636) and administration (90472), and the Typhoid vaccine 
(90691) and administration (90471), provided on December 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
October 17, 2021 to November 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the RAP was not submitted within the 
allowable timeframe. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
indicates that the RAP was not submitted within 5 days of the start of care.. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from October 17, 2021 to November 
13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
18, 2021, to May 26, 2021. 
 
You asked the Plan to pay for home health services. You say that the RAP claim was submitted. The Plan 
denied your request. The Plan says the RAP claim was submitted past the 5-day requirement. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the record 
does not support that the RAP was submitted within 5 calendar days after the start of care. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from May 18, 
2021, to May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the hip replacement, physical therapy 
evaluation and self-administered drugs provided from September 20, 2021, through September 21, 2021. 
 
You asked the Plan to reduce the copayment for the hip replacement, physical therapy evaluation and self-
administered drugs. You say that you were informed you were responsible for an overnight stay of $385. You 
say that the $4,000 cost is extremely difficult on a fixed income, and you believe the bill is an error. The Plan 
denied your request. The Plan says the claim processed 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). The rules also say that Medicare Part B generally does not pay for 
self-administered drugs. 
 
You have been asked to pay a total of $4,544.03 for the hip replacement, physical therapy evaluation and self-
administered drugs.  
 
Service Allowed Amount Standard Cost Member Liability 
Hip Replacement $14,931.15 30% $4,479.35 
Physical Therapy Evaluation $109.05 $40 $40 
Self-Administered Drugs $24.68 Not covered $24.68 
TOTAL:   $4,544.03 
 
The hip replacement falls within the "Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers" benefit category. The physical therapy evaluation falls within the 
"Outpatient rehabilitation services" benefit category. In addition, the self-administered drugs requested here are 
not among the types which are covered by Medicare Part B. 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 reduce the copayment 
for the hip replacement, physical therapy evaluation and self-administered drugs provided from September 20, 
2021, through September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of cancer treatment to be provided by 
an out-of-network (OON) provider. 
 You asked the Plan to pre-approve the continuation of cancer treatment with an OON provider. You say that 
the continuation of care with an OON provider is paramount to your continuity of care and well being. The 
Plan denied your request. The Plan says there are in-network providers available to provide this care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of cancer treatment 
with an OON provider. Our reviewer says that the requested continuation of care with an OON provider is not 
medically reasonable and necessary. Our physician reviewer found the out of network care is not necessary in 
this situation. As there are no compelling medical reasons to refer the patient out of network for radiation 
treatment, doing so would exceed the your medical need and therefore standard medical necessity criteria 
would not be met. 
 
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 continuation of cancer treatment with an OON provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the continuation of cancer treatment to be 
provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition is a major 
contributor of disability and lost productivity. The Plan denied your request. The Plan says unproven 
procedures are not covered by Medicare. 
 
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 requested services. Our physician 
reviewer found that the Vertiflex stabilization device is experimental. More research is needed to show safety 
and efficacy. Therefore, the request is not medically reasonable or 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 an interspinous stabilization device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 3, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical necessity of the procedure The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on September 3, 2021, have been met. Specifically, no documentation was provided from the ordering provider 
to support the medical necessity of the requested testing or how the testing would help the enrollees care 
program. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on 
September 3, 2021.