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

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided on April 07, 
2022. 
 
You asked the Plan to pay for durable medical equipment (DME). You say that you have proper authorization 
for the item and you should be reimbursed for the repair. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for durable medical 
equipment (DME) provided on April 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 27, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood draw (36415), basic metabolic panel (80048), and 
travel allowance for laboratory services (P9603) provided on August 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on 
this date. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the blood draw 
(36415), basic metabolic panel (80048), and travel allowance for laboratory services (P9603) provided on 
August 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs this device due to 
worsening heart failure. The Plan denied your request. The Plan says that the device has been determined to be 
of uncertain value. 
 
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. 
 
We looked at the file and the rules. Despite request, the Plan has not provided medical records pertaining to the 
device at issue. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pre-approve a 
CardioMEMS device.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210), biological materials 
(D4265), bone replacement graft (D7953), and a guided tissue regeneration (D4342). 
 
You asked the Plan to pre-approve a surgical extraction, surgical removal of residual tooth roots, biological 
materials bone replacement graft, and a guided tissue regeneration. You say that these services are medically 
necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a surgical 
extraction, surgical removal of residual tooth roots, biological materials bone replacement graft, and a guided 
tissue regeneration when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a surgical extraction have not been met. Biological materials bone replacement graft and a guided 
tissue regeneration are not covered benefits. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210), biological materials (D4265), bone replacement graft (D7953), and a guided tissue 
regeneration (D4342).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that all facility seating and wheelchairs have 
been trialed with no success. The Plan denied your request. The Plan says the device is not covered in a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The records show that a power wheelchair is being requested for use in a SNF. Based on this information, we 
decided that the Medicare rules for coverage have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies 
 
You asked the Plan to pre-approve the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not use insulin with at least three daily injections and 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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 and 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 the CGM 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) supplies
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on July 30, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the transport was not related to the 
enrollee's hospice diagnosis. You also say that this should be paid. The Plan denied your request. The Plan says 
the enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B 
benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to 
know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on July 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and application of multi-layer 
compression system (29581) provided on June 6, 2019, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services provided were physical therapy 
visits and not for durable medical equipment. The Plan denied your request. The Plan says prior authorization 
was not obtained. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) and application of multi-layer 
compression system (29581) provided on June 6, 2019, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a step stool. 
 
You asked the Plan to pre-approve a step stool. You say that you are not able to get in your bed. The Plan 
denied your request. The Plan says the item is not covered under Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a step stool.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on June 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary for this enrollee. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0037U) provided on June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by 
code E0652. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0652 PCD is covered when specific criteria 
are met. 
 
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 services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document at least 
four weeks of regular, daily, multiple-hour home usage of a basic pump after careful in-person fitting, training, and supervision by a technician who is skilled in and who regularly and successfully uses the appliance. The 
criteria are not met; therefore, the PCD is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) described by code E0652.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you are being 
treated for low back pain. The records support multiple possible sources for your pain. The neurologic exam 
was non-specific for any pain cause. Additionally, there is no documentation of a recent trial and failure of 
reasonable and comprehensive conservative treatment. The Intracept procedure is not supported as reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve a long-term acute care hospital (LTACH) admission. 
 
You asked the Plan to pre-approve an LTACH admission. You say that you feel the LTACH admission is 
necessary due to your medical history, and you are not able to afford rehabilitation. The Plan denied your 
request. The Plan says that the member is receiving appropriate in-patient acute care and is currently unstable 
for transfer to an LTACH. 
 
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 Plan failed to provide medical records to be reviewed by a medical 
professional. The plan has failed to substantiate their denial. Without the medical records, an informed decision 
on whether an LTACH admission is medically necessary cannot be made. Therefore, we decided that the Plan 
has to pre-approve a long-term acute care hospital (LTACH) admission.  
 
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: 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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the member is 
receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital 
(LTACH). 
 
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 the medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to a lower level of 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with RSV infection, pneumonia, and sepsis. There is a history of multiple sclerosis with functional quadriplegia 
and neurogenic bladder. An admitting note lists a diagnosis of chronic obstructive pulmonary disease (COPD), 
but this is not included in subsequent hospital diagnoses and there are no pulmonary function tests. There is no 
arterial blood gas (ABG) done while stable to document chronic carbon dioxide retention. The records do not support that the home ventilator is reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on March 4, 2022, to March 11, 
2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree with the denial and the claim should be reconsidered. The Plan denied your request. The Plan says that 
principal diagnosis code A41.9 is not supported. 
 
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. Specifically, the Plan did not submit medical records to support their denial of 
payment at the originally billed DRG. Therefore, we decided that the Plan has to pay for the inpatient hospital 
services provided on March 4, 2022, to March 11, 2022, at the DRG originally billed.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0242U) provided on July 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0242U) provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for pain management. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no urgent or emergent medical condition. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for pain management.