Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for the Part B drugs, technetium and a regadenoson 
injection. We decided that the Plan does not have to waive the cost share for an ultrasound, stress test, and 
myocardial perfusion imaging.  
 
You asked the Plan to waive the cost share for an ultrasound, stress test, Part B drugs, and myocardial 
perfusion imaging. You say that these services were approved. The Plan says that you have been charged the 
correct cost sharing amount. 
 
We decided that the Plan has to waive the cost share for the Part B drugs, technetium and a regadenoson 
injection.  
 
The Plan asked you to pay a 20% coinsurance for technetium and a regadenson injection. According to 
Medicare, these Part B drugs are considered packaged services and are not separately payable. Therefore, we 
decided that the Plan has to waive the cost share for the Part B drugs, technetium and a regadenoson injection 
provided on December 1, 2021.  
 
We also decided that the Plan does not have to waive the cost share for an ultrasound, stress test, and 
myocardial perfusion imaging. 
 
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 $30 
copayment for in-network non-radiological diagnostic services, including a stress test. The Plan contract also 
says that enrollees must pay a $160 copayment for each in-network radiological diagnostic services. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$160 copayment for an ultrasound on November 18, 2021. You have also been asked to pay a $30 copayment 
for a stress test and a $160 copayment for myocardial perfusion imaging on December 1, 2021. An ultrasound, 
stress test, and myocardial perfusion imaging fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. 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 cost share for an ultrasound 
provided on November 18, 2021, and a stress test and myocardial perfusion imaging provided on December 1, 
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 Viberzi. 
 
You asked the Plan to pre-approve Viberzi. The Plan denied your request. The Plan says Viberzi is a self-
administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Viberzi.  
 
Benefits for Viberzi may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee did not meet the criteria. 
 
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 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 requested device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuous glucose monitor.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until more appropriate 
for a lower level of care. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not supported and will be considered not 
medically necessary at this time as it would not be clinically advantageous. 
 
 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 power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you would like to regain quality of 
life and go outside of your home without help. You have fallen in the past and had to have stitches. You also 
say the walker does not hold your body weight. The Plan denied your request. The Plan says there is no 
documentation of a mobility deficit which limits your ability to complete activities of daily living in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. There is no 
documentation supporting you need the requested power vehicle. The file also shows that you have an 
upcoming appointment with your provider on June 7, 2022, for a power operate vehicle (POV) review. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and 
including 300 pounds (K0800).
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 LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says you are receiving appropriate inpatient care at the current hospital 
and the LTACH would add no additional services. 
 
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 that you appear to be more stable and should only require short-term additional acute 
care services that can safely be completed at the current facility, until more appropriate for 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Qutenza. 
 
You asked the Plan to pre-approve Qutenza. The Plan denied your request. The Plan says the use of this drug is 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Qutenza. Our physician reviewer found 
that the record indicates the enrollee has a diagnosis of unspecified polyneuropathy. The FDA has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
documentation does not support that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Qutenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Qutenza.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the over-bed table (E0274). 
 
You asked the Plan to pre-approve Over-bed table. You say that you have been bed-ridden your whole life and 
suffer from sleep apnea. You do not have the proper equipment to eat. The Plan denied your request. The Plan 
says the requested over-bed table is a convenience item and is not covered. 
 
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 the over-bed table (E0274).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Repair of umbilical hernia (49585-59) provided on July 
25, 2021. 
 You asked the Plan to pay for code 49585. You say that the medical records support the use of modifier 59 
with code 49585 provided on July 25, 2021. The Plan denied your request. The Plan says the medical records 
do not support the use of modifier 59 with code 49585 provided on July 25, 2021. 
 
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 49585 is a column II code to column I code 44120; however, 49585 
was billed with a modifier.  
 
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 code 49585. Our reviewer says that the medical records do 
not support the use of modifier 59 with code 49585 provided on July 25, 2021. Our reviewer found the 
operative report does not describe the procedure was performed in a different anatomical area, and would be 
inclusive of the more comprehensive procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 49585 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Repair of umbilical hernia (49585-59) provided on July 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens, scleral, gas permeable (V2531) provided on 
November 10, 2021. 
 
You asked the Plan to pay for the contact lens. You say that these contacts are medically necessary for this 
enrollee. The Plan denied your request. The Plan says this item is excluded from coverage under Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. This includes contact lens, scleral, gas permeable (V2531) which is subject to the Medicare refractive 
lens statutory coverage exclusion. 
 
The services you asked the Plan to pay for are considered routine vision services are eyewear, and are not 
covered by Original Medicare. Based on the information provided, we decided that the Plan's rules for 
coverage of the contact lens have not been met. Therefore, we decided that the Plan does not have to pay for 
the contact lens, scleral, gas permeable (V2531) provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-segmental pneumatic compressor device, full arm 
(E0665). 
 
You asked the Plan to pre-approve pneumatic compressor device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says your request is not medically necessary because you do 
not have documented criteria of E0650 or E0651. There is no documentation of conservative therapy tried and 
failed, such as elevation, wrapping, diet restrictions, exercise or medications failed. 
 
The Plan follows Medicare rules. The rules state that pneumatic compression device-related accessories 
(E0665) are eligible for reimbursement only when the appropriate, related base pneumatic compression devices 
meet the applicable coverage criteria for that device. If the base device is not covered, related accessories are 
not eligible for reimbursement. 
 
 
 
 
 
 
 
 The file shows that E0665 doesnt meet coverage criteria because after multiple requests from the plan, there is 
no evidence that a base device is being requested in this case. Therefore, we decided that the Plan does not 
have to pre-approve a non-segmental pneumatic compressor device, full arm (E0665).
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says you are receiving the appropriate inpatient care at the 
current 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 are no services at the LTACH that you require, that is not already available and 
covered, at the current facility. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving the care she needs in the hospital 
where she is now and there is no need to transfer to the LTACH at this time. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent implantable 
defibrillator system, with transvenous lead(s), single or dual chamber (CPT code 33249). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee's request is not medically necessary because the enrollee's records show 
they do not have any of the problems that Medicare approves for this device. 
 
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 service. Our physician reviewer 
found the clinical documents do not show that the enrollee meets implant criteria for defibrillator insertion 
according to current guidelines. In the absence of such documentation, implantation of an automatic 
defibrillator would not be considered medically necessary in the management of this enrollee. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion or replacement of permanent implantable defibrillator system, with transvenous 
lead(s), single or dual chamber (CPT code 33249).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRAF genetic testing or waive the copayment for the 
outpatient surgery provided on September 9, 2021. 
 
You asked the Plan to pay for the BRAF genetic testing and to waive the copayment for the outpatient surgery. 
You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says 
the provided BRAF gene analysis provided on September 9, 2021, was not medically necessary. The Plan also 
says that the correct copayment applied for the outpatient surgery services per your contract with the Plan. 
 
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 BRAF genetic testing. Our reviewer says 
that the provided BRAF gene analysis provided on September 9, 2021, was not medically necessary. Our 
physician reviewer found the provided medical records do not provide any details as to the rationale or utility 
of the testing for the enrollee in this case. 
 
The rules also 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 $200 copayment for Outpatient surgery. You have been asked to pay a $200 copayment for the Outpatient 
surgery provided on September 9, 2021. This service falls within the Outpatient surgery benefit category. 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 pay for the BRAF genetic testing or waive the copayment 
for the outpatient surgery provided on September 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 20, 2020, to 
May 18, 2020. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the records do not support the services 
billed. 
 
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 home health services provided 
from March 20, 2020, to May 18, 2020, have been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from March 20, 2020, to May 18, 2020.