Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are
medically necessary. The Plan denied your request. The Plan says that that coverage beyond 190-day lifetime
limit is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided any documentation confirming the enrollee has
reached the benefit limit. Without documentation confirming the dates the enrollee was in an inpatient
psychiatric hospital our office is unable to substantiate the Plan's denial rationale. Therefore, we decided that
the Plan has to pre-approve continued inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that this care is medically necessary for your pain. 
The Plan denied your request. The Plan says medically necessary care is available in-network for the enrollee's 
condition. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation submitted does not show that the enrollee uses insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 or 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 monitor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose 
monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the incisional biopsy of oral tissue (D7286) and limited oral evaluation 
(D0140) provided on April 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that this is not a dental service. You say that you had 
a biopsy in April. You say you had a procedure of removal of a portion of your tongue that was cancerous. You 
say that this should have been considered a medical service, not dental as you had no work done on your teeth. 
The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says that 
the dental services were medically necessary. Our physician reviewer found the provided documentation 
confirms that the services that were provided were medical in nature. Therefore, the reviewer found that the 
services were medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Specifically, the file shows that the services 
you received are medical in nature. Therefore, we decided that the Plan has to pay for the incisional biopsy of 
oral tissue (D7286) and limited oral evaluation (D0140) provided on April 19, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing for Noonan spectrum disorders (81442) 
provided on June 11, 2021. 
 
You asked the Plan to pay for the genetic testing for Noonan spectrum disorders. You say that this was 
medically necessary testing and should be paid. The Plan denied your request. The Plan says Medicare denies 
coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented 
cardiovascular disease. 
 The Plan must follow Medicare rules. Medicare rules say that genetic testing is not covered when performed on 
patients without signs and symptoms of a specific disease for which testing is requested.  
 
We looked at the file and Medicare rules. The panel described by this code is for diagnosis of Noonan spectrum 
disorders. The only diagnoses on the claim are hypertension, snoring, and family history of ischemic heart 
disease. There is no evidence of any signs or symptoms of Noonan syndrome, nor any mention in the record of 
a suspicion of this particular diagnosis. Based on this information, we decided that Medicare rules for coverage 
of the genetic testing for Noonan spectrum disorders have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing for Noonan spectrum disorders (81442) provided on June 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is needed to ease the pain caused by 
inflammation and arthritis. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 there is no documentation provided indicating medical necessity for the 
admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 

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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips. 
 
You asked the Plan to pre-approve OneTouch Verio test strips. You say that this is necessary for you. The Plan 
denied your request. The Plan says that there is no clinical rationale as to why member cannot use a preferred 
product. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiary's medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of blood glucose meter. Without this, medical necessity 
cannot be established. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio test 
strips.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services (00142) provided on June 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
billed with an invalid or missing modifier. 
 
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. In this case, code 00142 was billed with modifiers -QX, -QS, and -22. The Plan 
has not provided documentation showing that these modifiers are invalid, nor has it provided documentation 
showing that a modifier is missing. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the anesthesia services (00142) provided on 
June 25, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on March 12, 2021. 
 
You asked the Plan to pay for the services provided. You say that the test is a standard of care. The Plan denied 
your request. The Plan says the professional interpretation of a diagnostic test must be separately billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. We find that the services at issue were rendered in an outpatient hospital 
setting. This means that only the professional component is payable. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the pathology services provided on March 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 
be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the ankle 
(73721). 
 
You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of 
the requested service. The Plan denied your request. The Plan says MRI of the ankle is not the most appropriate 
test to be done to evaluate the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical rationale for the requested MRI. There is no documentation of ankle 
instability or abnormal physical exam findings. The review has determined that the requested MRI of the ankle 
is not medically necessary or reasonable. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the magnetic resonance imaging (MRI) of the ankle (73721).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left knee primary 
osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Synvisc is not reasonable 
or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the spinal nerve injection procedures you 
had at an ambulatory surgery center on March 18, 2021, and May 18, 2021. 
 
You asked the Plan to reduce the copayments for the spinal nerve injection procedures. You say that your 
copayment should only be a specialist visit, not a facility fee. The Plan denied your request. The Plan says you 
were charged these copayments 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 a $275 
copayment for ambulatory surgery center services.  
 
We confirmed that the facility where you received these services is considered an ambulatory surgery center. 
You have been asked to pay a $275 copayment for each of the spinal nerve injection procedures. 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 reduce the copayments for the spinal nerve injection procedures you had at an ambulatory 
surgery center on March 18, 2021, and May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no documentation of a medical diagnosis for which this testing may be done, either on 
the claim form or in the available documentation. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the services were provided in the absence of signs, symptoms, complaints or personal history of a disease 
or injury. There is no documentation of a medical diagnosis for which this testing may be done.  
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 pay for laboratory services provided to the enrollee on March 4, 2021.