Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the deductible for the office visit. We decided that the Plan does not 
have to waive the coinsurance for the office visit.  
 
You asked the Plan to waive the deductible for the office visit provided on May 31, 2022. You say that this 
should have been billed as an Annual Wellness appointment. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
We decided that the Plan has to waive the deductible for the office visit.  
 
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 file does not support how much of the deductible has been met. 
Without this information, we cannot determine if the correct amount of the deductible was applied to this 
service. Therefore, we decided that the Plan has to waive the deductible for the office visit.  
 
We also decided that the Plan does not have to waive the coinsurance for the office visit. 
 
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 10% 
coinsurance for Doctor and Other Health Care Provider Services.  
 
You have been asked to pay 10% coinsurance for the evaluation and management service. This service falls 
within the Doctor and Other Health Care Provider 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 coinsurance for the office visit. 
 
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 spinal cord stimulator implantation. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a 
spinal cord stimulator. 
 
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered if certain 
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 spinal cord stimulator. Our reviewer says that the enrollee does not meet the criteria for a spinal cord stimulator. Our physician reviewer found the 
enrollee does not have an evidence-based indication for a spinal cord stimulator trial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal cord stimulator implantation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81000, 82270, 81453) on June 2, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with the denial of this claim and 
are requesting reconsideration for payment. The Plan denied your request. The Plan says the submitted medical 
records do not indicate that the laboratory tests were performed on the billed date of service. 
 
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 laboratory services (81000, 82270, 
81453) on June 2, 2022, have been met. Medical records do not support the services billed or the date of 
service. The records show that multiple attempts were made to contact the provider for additional information. 
Therefore, we decided that the Plan does not have to pay for laboratory services (81000, 82270, 81453) on June 
2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for IV infusions and lymphocyte immune 
globulin provided on January 12, 2022. 
 
You asked the Plan to waive the coinsurance for IV infusions and lymphocyte immune globulin. You say that 
you should not be responsible to pay this. 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 20% 
coinsurance for renal dialysis services provided in an outpatient hospital setting.  
 
 
 
 
 You have been asked to pay $507.21 for IV infusions and lymphocyte immune globulin. These items/services 
fall within the Medicare Part B prescription drugs 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 
coinsurance for IV infusions and lymphocyte immune globulin provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D3310, D2950, D9230, D7270, D7910) 
on April 1, 2021, to April 14, 2021. 
 
You asked the Plan to pay for the dental services (D3310, D2950, D9230, D7270, D7910). You say that the 
services received were medically necessary. The Plan denied your request. The Plan says The services (D7270, 
D7910) are not covered under the members contract under regular dental benefits. Services (D3310, D2950, 
D9230) were denied for the amount above $1000 limit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services (D3310, D2950, D9230, D7270, D7910) on April 1, 2021, to April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor (CPT code E0667) and the pneumatic compressor, segmental home model with calibrated gradient 
pressure (E0652). 
 
You asked the Plan to pre-approve the DME. You say that the immediate relief of pressure from using the 
equipment is essential to the continuous improvement of the leg the result of the use of the wrap are immediate 
and increased mobility and comfort. The Plan denied your request. The Plan says there are in-network 
provider(s) within a reasonable distance from your location that can provide this service when medically 
necessary. The Plan states your records do not show failure of a four-week trial of maximal conservative 
therapy for your condition. 
 
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 DME. Our physician reviewer 
found there is no documentation that the segmental pneumatic compression device at issue in this case meets 
all Medicare criteria for medically reasonable and necessary for you. Provided records do not document at least 
four weeks of regular, daily, multiple-hour home usage of a standard pneumatic compression device after 
careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and 
successfully uses the appliance provided as required by the LCD: Pneumatic Compression Devices - L33829. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667) and the 
pneumatic compressor, segmental home model with calibrated gradient pressure (E0652).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistance services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence provided warranting the additional units requested given the needs 
of the enrollee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that noo medical notes from the enrollees treating physician are provided documenting an order or need 
for additional personal care services beyond what have already been approved. The provided records do not 
document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate any further personal care services beyond what have already been approved. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve personal care assistance services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occipital nerve block (CPT code 64405) 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 services are 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 occipital nerve 
block (CPT code 64405) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, sacroiliac joint, percutaneous or 
minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when 
performed, and placement of transfixing device (CPT code 27279). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found detailed documentation is not evident regarding the trial and failure of conservative treatment directed at 
the sacroiliac spine. Additionally, there are no diagnostic imaging studies provided to corroborate sacroiliac 
pathology. Moreover, the enrollee has only had one SIJ injection. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the medical records provided do not meet the requirements listed in the LCD for Medicare 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect 
visualization), with image guidance, includes obtaining bone graft when performed, and placement of 
transfixing device (CPT code 27279).
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 this would help the enrollee get back to their daily 
life so they could go home. The Plan denied your request. The Plan says the criteria for admission to the Acute 
Inpatient Rehabilitation setting have not been met. The enrollee's ongoing skilled therapy and nursing needs 
can be provided at a lower level of care such as at a Skilled Nursing Facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor and supplies provided on April 
8, 2022. 
 
You asked the Plan to pay for a continuous glucose monitor and supplies. You say that this is supported in the 
records. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 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 a 
continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have 
to pay for a continuous glucose monitor and supplies provided on April 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 8 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 8 routine transportation trips. You say that you need 
transportation to get to medical appointments. The Plan denied your request. The Plan says your benefit only 
allows 24 trips for this service. You currently have 3 trips remaining and you will have exceeded your benefit 
limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 8 routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0856, E1028, 
E0955, E2361, E1002, E2310, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary due to immobility and the enrollee is a significant risk for skin breakdown and injury due 
to falls with high fall and transfer risk. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for a base code power wheelchair group 3 with single power option. 
 
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.  
 
 
 
 
 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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does 
not have a high risk for skin breakdown and he does not have intermittent catheterization of a ventilator. The 
enrollee has adequate strength in his left upper extremity and leg to manage standard 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0856, E1028, E0955, E2361, 
E1002, E2310, E2607).
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 a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 a home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have severe chronic obstructive pulmonary disease (COPD) with a recent exacerbation. 
However, there is no documentation of chronic carbon dioxide (CO2) retention on an arterial blood gases 
(ABG) done while you are stable. If chronic CO2 retention is present, you may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. But Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 meets the medical management criteria 
and needs physician oversight. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as home health services in an 
assisted living facility. 
 
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 enrollee has a history of hypertension, coronary artery disease, a pacemaker and 
is living at home with dizziness and frequent falls. The record shows the enrollee's medical problems are stable, 
and there are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation 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 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.