Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Incision, extensor tendon sheath, wrist (25000) provided 
on September 27, 2021. 
 
You asked the Plan to pay for code 25000. You say that the medical records support the billing of code 25000 
provided on September 27, 2021. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 25000 provided on September 27, 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, the CPT Code Manual definition of code 25000 is Incision, extensor tendon sheath, wrist (eg, de 
Quervains disease). 
 
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 25000. Our reviewer says that the medical records do 
not support the billing of code 25000 provided on September 27, 2021.  Our reviewer found code 25447 includes the code for tendon sheath excision 25000. It should not be unbundled 
and should not be approved. 
 
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 25000 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Incision, extensor tendon sheath, wrist (25000) provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the documentation submitted in insufficient in proving medical 
necessity for these items and multiple attempts were made to obtain most recent medical records. 
 
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. 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 CGM and supplies have been met. 
Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) 
(K0554) and supplies (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the health plans denial should be upheld. You do not require the intensity of services 
provided at an IRF. Specifically, you are not shown to require fifteen (15) hours per week of rehabilitative 
services and regular physician evaluation. Your care needs can be met at 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring of interstitial 
tissue fluid via a subcutaneous sensor for a minimum of 72 hours (95250) provided on November 9, 2021. 
 
You asked the Plan to pay for the ambulatory continuous glucose monitoring. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the denial of ambulatory continuous glucose 
monitoring was appropriate given the clinical scenario and guidance presented. 
 
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 ambulatory continuous glucose 
monitoring. Our reviewer says that the ambulatory continuous glucose monitoring is not considered medically 
reasonable and necessary in this case. Our physician reviewer found continuous glucose monitoring is covered 
when the patient is on multiple daily injections of insulin. Our reviewer found that this patient is not taking 
insulin and is on 3 medications which do not cause low blood glucose. Our physician reviewer also found that 
it is unclear why the continuous glucose monitoring needed to be done and the usual coverage criteria are not 
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 ambulatory continuous glucose monitoring have not been met. Therefore, 
we decided that the Plan does not have to pay for the ambulatory continuous glucose monitoring of interstitial 
tissue fluid via a subcutaneous sensor for a minimum of 72 hours (95250) provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on 
November 5, 2021. 
 
You asked the Plan to pay for these items. You say that this should be covered under the enrollee's out of 
network benefit. The Plan denied your request. The Plan says that the physician named on the order denies 
ordering this brace for the enrollee. 
 
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. The physician listed as the ordering physician indicated 
that he did not order these items for the enrollee. 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 the knee orthosis and sleeve provided to the enrollee on November 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on December 1, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee required two transports for the same date of service for dialysis treatment, and you would like this 
claim to be reprocessed for payment. The Plan denied your request. The Plan says the policy covers non-
emergency ambulance transportation when it is the only way to safely and adequately transport a member or if 
other means of transporting a member are unsafe due to a medical condition. The Plan also says that this claim 
does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that the ambulance transportation to the enrollees 
dialysis appointment was not medically necessary. Our physician reviewer found the enrollee did not require 
the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Our reviewer found that transportation could have been provided by other means (stretcher van, 
wheelchair van) without endangering the enrollees condition. Our physician reviewer also found that a prudent 
layperson would not believe that immediate medical attention was required for someone attending a regularly 
scheduled appointment. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (G0483) provided November 29, 
2021. 
 You asked the Plan to pay for the laboratory service. You say that you request reconsideration and payment in 
full for the toxicology drug screen performed. The Plan denied your request. The Plan says the request for 
definitive urine drug testing of this number of drug classes is considered not medically reasonable and 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the medical record sent by the provider shows a definitive 
UDT panel for multiple drug classes was performed but does not show screening test results which are positive 
or inconsistent with prescription medications, dosing schedules, or history and expected results. The 
items/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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive urine drug testing (G0483) provided November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are 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 and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inversion table. 
 
You asked the Plan to pre-approve the table. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no qualifying condition for this device. 
 
The Plan must follow Medicare rules. Medicare rules say that traction equipment is covered if the patient 
has orthopedic impairment requiring traction equipment which prevents ambulation during the period of 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 table. Our reviewer says that the 
requested table is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is limited published, large-scale, long-term peer-reviewed literature that shows lumbar traction to 
be an effective and/or safe treatment for the noted pathology. You were being treated for neck pain; back pain; 
spinal stenosis, lumbar region without neurogenic claudication; herniated disc or slipped disc; degenerative 
disc disease. He presented with chronic back pain and a history of back surgery. The exam did not document 
any lumbar spine findings. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, requested inversion table, 
in this case, 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 table have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an inversion table.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to place an Inspan device for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that use of this device is better than regular spine 
surgery for the patient's problems. The Plan denied your request. The Plan says there are not enough studies to 
show that this device is better than regular spine surgery, or will help in care. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed. 
 
 
 
 
 
 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve surgery to place an Inspan device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
requirements for Prolia have not been met. Our physician reviewer found the Plan requires a trial of an oral 
bisphosphonate drug and zoledronic acid (generic Reclast) before they will approve the requested drug, Prolia. 
Based on the medical records provided, the patient has tried and failed oral bisphosphonate therapy but has not 
tried and failed zoledronic acid. There is no indication that zoledronic acid would likely be less effective or 
have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You 
are medically stable and does not need physical medicine and rehabilitation physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no rehab nursing needs identified or documented in the record. You do not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach to daily therapy in an IRF. While you may benefit from physical, speech and occupation therapy, 
your rehab can be safely provided at a lower intensity and alternate setting such as in an SNF. Our physician 
reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99211) provided on August 22, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration because you were in 
quarantine and told the Plan would cover this service. The Plan denied your request. The Plan says there is 
insufficient documentation. 
 
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 office visit (99211) provided on 
August 22, 2021. have been met. Specifically, the documentation submitted does not include any clinical 
information to validate the services that were billed. The records submitted do not support that an office visit 
was rendered on the billed date of service. Therefore, we decided that the Plan does not have to pay for the 
office visit (99211) provided on August 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a computed tomography (CT) scan of the 
chest and the reading of the CT scan results provided on November 16, 2021. We also decided that the Plan 
does not have to waive the copayment for a pulmonology specialist office visit provided on November 23, 
2021. 
 
You asked the Plan to waive the copayments for a CT scan, reading the CT scan results, and a specialist office 
visit. You say that no one ever said you were going to have a charge for this test. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount.  
 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 $175 
copayment for advanced imaging services, including CT scans. The Plan contract says that enrollees must pay 
a $25 copayment for a specialist office visit. 
 
The record shows these claims were approved, and that you have a cost sharing amount. You have been asked 
to pay a $118.78 copayment for a CT scan on November 16, 2021. You have also been asked to pay a $56.22 
copayment for the reading of the CT scan results on November 16, 2021. You have been asked to pay a total 
combined copayment of $175 ($118.78 copayment + $56.22 copayment = $175). A CT scan and the reading of 
the CT scan results fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category.  
 
You have been asked to pay a $25 copayment for a specialist office visit on November 23, 2021. A specialist 
office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 copayments for a computed tomography (CT) scan of the chest and the 
reading of the CT scan results provided on November 16, 2021. We also decided that the Plan does not have to 
waive the copayment for a pulmonology specialist office visit provided on November 23, 2021.