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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
electronic connection (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection. 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 an expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has adequate strength to manage standard 
power drive controls.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, harness, and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness 
(E2313), and electronic connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - three surfaces, posterior (D2393), 
and protective restoration (D2940) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had $993 left of your 2022 annual 
maximum that should have applied toward the balance of services. The Plan denied your request. The Plan says 
your benefit for the resin-based composite - three surfaces, posterior has already been exhausted. The Plan also 
says that the protective restoration is not covered under the Plans dental benefits. 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the resin-based composite - three surfaces, posterior was exhausted on date of service 
September 20, 2022, and the protective restoration is not listed among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite - three surfaces, posterior 
(D2393), and protective restoration (D2940) provided on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee takes the proper amount of insulin per 
day. The Plan denied your request. The Plan says that the enrollee has not had a visit with their doctor within 
the past 6 months and will be seen every 6 months for monitoring. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM is medically necessary. Our physician reviewer found that the enrollee is adjusting doses according to 
blood glucose level, is on multiple doses of insulin, and has been seen within the past 6 months of the request 
for the CGM as well as most recently on March 19, 2023. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pre-
approve a continuous glucose monitor (CGM).  
 
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: Favorable

 
We decided that the Plan has to pay for inpatient hospital stay provided from August 27, 2021, through 
September 5, 2021 
 
You asked the Plan to pay for an inpatient hospital stay. You say that the claim needs to be reprocessed. The 
Plan denied your request. The Plan says that Original Medicare is responsible for payment. 
 
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 says the enrollee was enrolled in hospice and Original 
Medicare is responsible for payment. The records show the enrollee did not enroll in hospice until the 
discharge day, which would not require Original Medicare to pay for this claim This means that the Plan has 
not provided a valid reason for denying payment of the inpatient hospital stay. It is the burden of the Health 
Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pay for the  inpatient hospital stay provided from 
August 27, 2021, through September 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for oral evaluation (D0120), prophylaxis 
(D1110), bitewing x-rays (D0210) and intra and extraoral images (D0350) provided on December 22, 2022. 
 
You asked the Plan to waive the copayment for evaluation, prophylaxis, and imaging. You say that this should 
be covered. The Plan denied your request. The Plan says this cost sharing was charged 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). Your contract with the Plan clearly says that you must pay $15 
copayment per service during the visit for covered routine dental services when provided by an in-network 
provider.  
 
 You have been asked to pay $58.79 total copayment for evaluation, prophylaxis and imaging. This item/service 
falls within the dental services 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 copayment for oral 
evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0210) and intra and extraoral images (D0350) 
provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 15, 2022. 
 
You asked the Plan to pay for the office visit. You say that the providers are not contracted but the facility is a 
network facility. 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 the office visit provided 
on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit and consultation (99204 and 99214) to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is an in-network provider that can perform the services you need. 
 
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 
the office visit and consultation (99204 and 99214) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 23, 2021, to 
August 2, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A40.0, described as sepsis 
due to streptococcus, group A. 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 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found testing did not reveal any signs of organ damage beyond baseline to 
suggest a dysregulated response to systemic infection causing organ failure. The enrollee does not meet Sepsis 
3 criteria based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 23, 2021, to August 2, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve FoundationOne CDx (F1CDx) testing (0037U). 
 
You asked the Plan to pre-approve FoundationOne CDx (F1CDx) testing. You say that the enrollee meets 
criteria for this testing. The Plan denied your request. The Plan says that the enrollee does not have metastatic 
disease or unresectable disease. 
 
The Plan follows Medicare rules. Medicare rules say that for coverage of this test, the enrollee must meet the 
criteria in the rules section of this letter.  
 
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 FoundationOne CDx (F1CDx) testing. 
Our reviewer says that this service is medically reasonable and necessary. Our physician reviewer found that 
the enrollee has advanced unresectable hepatocellular cholangiocarcinoma. NGS is a standard of care per the 
National Comprehensive Cancer Network (NCCN) Guidelines. Thus, the enrollee meets criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FoundationOne CDx (F1CDx) testing have been met. Therefore, we decided 
that the Plan has to pre-approve FoundationOne CDx (F1CDx) testing (0037U).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal fusion surgery (20930, 22633, 20936, 22634). 
 
You asked the Plan to pre-approve the spinal fusion surgery. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is 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 spinal fusion surgery. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented spinal instability, fracture, or lesion. 
 
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 spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the spinal fusion surgery (20930, 22633, 20936, 22634).
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 the enrollee displays decreased safety awareness and 
impulsive behavior and would benefit from further education for safe mobility, especially with assistive 
devices. The Plan denied your request. The Plan says the enrollee does not need a medical team to manage your 
health care decisions, medically necessary care may be provided safely in a lower level of care. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external catheter (K1006). 
 
You asked the Plan to pre-approve an external catheter. You say that you cannot wait for the catheter. You say 
that you are having much difficulty getting to the bathroom in time. You also say that it is not safe for you to 
attempt to get to the bathroom quickly because of your current medical condition. The Plan denied your 
request. The Plan says the requested item is not a covered benefit. 
 
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 an external catheter (K1006).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on December 04, 2021, to 
January 05, 2022. 
 
You asked the Plan to pay for outpatient services. You say that you are requesting reconsideration. 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 outpatient services 
provided on December 04, 2021, to January 05, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (G0483, 80307) provided on May 11, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says that the criteria for these services are not met. 
 
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 has not provided a clear reason for the denial of these 
services. The Plan appears to have re-coded G0483 to G0481, but no reason for this change was provided or 
supported with evidence. In addition, the Plan states that the criteria for code 80307 are not met, however no 
explanation of the relevant criteria is provided. The Plan has not substantiated their denial of these services as 
they were submitted in this case. Therefore, we decided that the Plan has to pay for drug testing services 
(G0483, 80307) provided on May 11, 2022.  
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not able to move around on your own and 
would like assistance with strengthening yourself. The Plan denied your request. The Plan says your records do 
not show that you need an intensive team for your care, services needed can be provided safely in other 
settings, a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tocilizumab injection (J3262). 
 You asked the Plan to pre-approve Tocilizumab injection. You say that Tocilizumab is medically necessary. 
The Plan denied your request. The Plan says a trial of self-administered Tocilizumab is required before 
injection by a provider can be considered. 
 
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 Tocilizumab injection. Our reviewer 
says that the Tocilizumab injection is not medically necessary. Our physician reviewer found the records do not 
show a trial of the plan preferred alternative, or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tocilizumab injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Tocilizumab injection (J3262).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast reconstruction to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there is an in-network provider that can perform the services you 
need. 
 
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 
the breast reconstruction to be provided by an out-of-network provider.