Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for mental status changes and a urinary tract infection. 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. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 pay for the supply allowance used with a therapeutic CGM device 
(K0553) provided February 3, 2022.  
You asked the Plan to pay for the CGM supply allowance. You say that please see attached medical 
documentation that meet all the criteria for K0553. The Plan denied your request. The Plan says the medical 
necessity criteria has 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 Evidence of Coverage specifically says that Plan covers diabetic 
supplies made by OneTouch/LifeScan. The Plan exclusively covers OneTouch/LifeScan glucose monitors and 
test strips. The Plan does not cover other brands of monitors and test strips unless you or your provider requests 
a medical exception, and it is approved. The Plan verified that there is no authorization on file for the Freestyle 
Libre. Based on this information, we decided that Medicare rules for coverage of the CGM supply allowance 
have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance used with 
a therapeutic CGM device (K0553) provided February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5241) and a dispensing fee (V5241) 
provided on May 19, 2022. 
 
You asked the Plan to pay for a hearing aid (V5241) and a dispensing fee (V5241). You say that you received 
the Explanation of Benefits, and it does not show the $500 Plan payment for your hearing aids. The Plan denied 
your request. The Plan says your policy covers $500 for a hearing aid for both ears combined every three years. 
The Plan also says that a review of claims shows that the benefit was applied for services on January 23, 2020, 
July 1, 2021, and July 30, 2021. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
$500 for a hearing aid for both ears combined every three years.  
 
 
  We looked at this physician's review, the file, and the Plan's rules. The records show that the Plan covered the 
$500 for our hearing aid for both ears on January 23, 2020, July 1, 2021, and July 30, 2021. Based on this 
information, we decided that the Plan's rules for coverage of a hearing aid (V5241) and a dispensing fee 
(V5241) have not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid (V5241) 
and a dispensing fee (V5241) provided on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect Test provided on April 12, 2022. 
 
You asked the Plan to pay for the Cxbladder Detect Test. You say that the service was medically necessary and 
payable. The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the CxBladder Detect Test is not covered by 
Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cxbladder Detect Test have not been met. Therefore, we decided that the Plan does not have to 
pay for the Cxbladder Detect Test provided on April 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air transportation provided on February 27, 2022. 
 
You asked the Plan to pay for the air transportation. You say that you would like reconsideration because this 
transportation meets the definition of inpatient hospital services. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that transportation back to the United States from 
another country is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air transportation have not been met. Specifically, the requested air transportation back to the 
United States is not a covered benefit under Medicare or your plan. Therefore, we decided that the Plan does 
not have to pay for air transportation provided on February 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulance for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulance for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
March 26, 2022, to March 27, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
inpatient admission criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 26, 2022, to 
March 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #1 (D7210) provided on May 18, 2022. 
 
You asked the Plan to pay for an extraction. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says an extraction (D7210) is not covered by your supplemental 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, 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 an 
extraction of tooth #1 (D7210) provided on May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive sacroiliac (SI) joint fusion surgery 
(27279, C1776, C1889) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the sources of pain in the enrollee's right buttock region may be 
multifactorial in nature given the history of lumbar spine disease with radiculopathy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of a recent trial and failure of physical therapy for back pain. Si joint fusion for back pain 
without SI joint instability remains experimental. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally invasive sacroiliac (SI) joint fusion surgery (27279, C1776, C1889) for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge management (99239) provided on April 
14, 2022. 
 
You asked the Plan to pay for hospital discharge care. You say that this care was medically necessary and was 
supported in the medical record. The Plan denied your request. The Plan says this service is included in the 
global surgery package for procedure 49083 billed for the same date of service. This claim was not billed with 
an appropriate modifier to show that this service is unrelated to this global surgery procedure. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, this service is included in the 
global surgery package for procedure 49083. Of note, 99239 was not billed with an appropriate modifier to 
indicate that this service would be separately payable. Based on this information, we decided that Medicare 
rules for coverage of hospital discharge care have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital discharge management (99239) provided on April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection, Botulinum toxin type A (Botox) 
onabotulinumtoxinA) (J0585) and chemodenervation of muscle(s) (64615) provided May 17, 2022. 
 
You asked the Plan to pay for the injection services. You say that the records provided support the necessity of 
the service in dispute. The Plan denied your request. The Plan says providers must bill the Group Health Plan 
before billing Medicare, and the primary payer payment information that appears on all primary payer 
remittance advices must appear on the claim submitted to Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another Plan 
as the primary insurer that has been primary as of September 13, 2021. As the secondary insurer, the Plan 
cannot be held responsible for the injection services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the injection, Botulinum toxin type A 
(Botox) onabotulinumtoxinA) (J0585) and chemodenervation of muscle(s) (64615) provided May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on April 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 13, 
2021. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary and were 
billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of therapy services have not been met. Specifically, the documentation shows that this claim was 
billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical Therapy Assistant. 
There is no indication that the Nurse Practitioner was present on site while the therapy services were being 
rendered. The incident-to requirements have not been met in this case. Therefore, we decided that the Plan does 
not have to pay for therapeutic exercises (97110) provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702). 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the device is medically 
necessary. The Plan denied your request. The Plan says the device is an experimental and investigational 
procedure and not covered by Medicare. 
 
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 a MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro powered arm brace have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection with triamcinolone acetonide preservative-free 
(J3300) billed for date of service January 13, 2022. 
 
You asked the Plan to pay for a triamcinolone acetonide injection. You say that the service at issue was billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met because the 
available medical records do not support the service billed. 
 
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 J3300 is "Injection, triamcinolone acetonide, preservative 
free, 1 mg." 
 
We find that CPT code J3300 is not supported in the medical record. Specifically, the available medical records 
state that the enrollee was injected not with triamcinolone acetonide but with triamcinolone diacetate. Based on 
this information, we decided that Medicare rules for coverage of a triamcinolone acetonide injection have not been met. Therefore, we decided that the Plan does not have to pay for an injection with triamcinolone 
acetonide preservative-free (J3300) billed for date of service January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis A vaccine (90632) provided on May 11, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you were advised to have the Hepatitis A and B 
vaccines due to your medical condition. You also say that your doctor ordered this. The Plan denied your 
request. The Plan says the vaccine received, and the administration cost is covered only under your Part D 
benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The Hepatitis A vaccine you received is not covered under Medicare Part B. Therefore, we decided that the 
Plan does not have to pay for the Hepatitis A vaccine (90632) provided on May 11, 2022.  
 
 
 
 
 
 
 
 Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic testing must be billed with 
the DEX-Z code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
DEX_Z code. 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 pay for the laboratory services rendered on 
January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits (99213) provided from April 6, 2021, to 
December 28, 2021. 
 
You asked the Plan to pay for the physician services. You say that you have been seeing this provider for the 
last 3 years. You say that you wish to continue to see them. You also say that these services should be covered. 
The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also 
says that payment cannot be made for services performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visits (99213) provided from April 6, 2021, to December 28, 2021.