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

 
We decided that the Plan does not have to pre-approve a skin graft. 
 
You asked the Plan to pre-approve the graft. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that the arterial blood supply to the affected area has been 
documented as sufficient or that the underlying osteomyelitis has resolved nor that the enrollee has achieved 
tobacco abstinence. 
 
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 graft. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that you have a healing diabetic foot ulcer in the setting of acute osteomyelitis. The 
record does not indicate that you have completed treatment for the infection. The record indicates that the ulcer 
is decreasing in size by a third in the last interval visit. The record does not document the evaluation of your 
peripheral vascular status. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 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 graft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skin graft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a C7-T3 spine fusion. 
 
You asked the Plan to pre-approve a C7-T3 spine fusion. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 C7-T3 spine fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had prior thoraic and lumbar fusion and now has degenerative disc 
disease (ddd) at level above with spondylolisthesis. There is no severe deformity or severe stenosis with 
neurolgic impairment. A trial of physical therapy (PT) for 6 weeks is needed. There is documented PT trial for 
6 weeks. 
 
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 C7-T3 spine fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a C7-T3 spine fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 transmitter and Dexcom G6 sensor. 
 
You asked the Plan to pre-approve Dexcom G6 transmitter and sensor. You say that the records provided 
should support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for the Dexcom G6 transmitter and Dexcom G6 sensor. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of Dexcom G6 transmitter and Dexcom G6 sensor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 transmitter 
and Dexcom G6 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that the requested CGM is necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on December 6, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says unauthorized, non-plan 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 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 medical services provided on December 6, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 2021. 
 
You asked the Plan to pay for procedure code 87481, 87640, 87653, and 87798. You say that you disagree with 
the denial. The Plan denied your request. The Plan says the services are not covered. 
 
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, we have confirmed that codes 87481, 87640, 87653, and 87798 are column II codes to column I 
code 87801. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met.  
 
The CPT Code Manual definition of code 87801 is infectious agent detection by nucleic acid (DNA or RNA), 
multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records do not include 
documentation of infectious agent detection by nucleic acid. 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 June 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing care (99308) provided on March 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skilled nursing care. You say that the rendering provider was the only doctor 
available on call to see the enrollee. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advance. 
 
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 the skilled nursing care (99308) provided on 
March 22, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the Plan's 
contract. 
 
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 72 one-way transportation trips per year, not to exceed 50 miles of driving 
distance per one-way trip. 
 We looked at your request, the records in the case file, and the rules. The file shows that you are requesting an 
additional 51 miles over your allowed benefit limit for transportation trips, totaling 101 miles per one-way trip. 
Your contract with the Plan clearly states you are only covered for 50 miles per one-way trip. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve SNF admission. You say that you were told that you were in-network. You 
say that you need professional help to get back your strength and mobility. The Plan denied your request. The 
Plan says based on Medicare guidelines and the information we have about your condition you do not meet all 
the requirements. 
 
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 admission. Our reviewer says that 
you are not receiving any skilled rehab services and appear to be independent with an exercise program. 
Admission to the nursing facility at a skilled level of care for inpatient skilled services is not medically 
necessary. Our physician reviewer found you have a medical history including cardiac disease, previous stroke 
and osteoarthritis with previous total knee replacement who has been residing in a skilled nursing facility at a 
custodial level of care since February 28, 2022. You had complications including an infected knee prosthetic 
joint that required parental antibiotics, surgery and wound care. You suffered a wound on the calf from the 
knee immobilizer that has required topical and oral antibiotics. The documentation indicates your wounds are 
decreasing in size although treated for infection with oral antibiotics and you remain medically stable.  
 
You do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF admission.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, 
Orthovisc, Synvisc, or Synvisc-One. 
 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 Gelsyn-3. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
indicate that the enrollee has tried and failed the preferred drugs, Orthovisc, Synvisc, or Synvisc-One. The 
reviewer also found that there is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the 
step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3 (J7328).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing (81479) provided on November 27, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
with a date of service inconsistent with Medicare rules governing laboratory services. 
 
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 81479 is not supported in the medical record for the billed date of service. Specifically, 
the records show that the specimen was collected on September 14, 2021. The testing must be billed for the 
date of service that the specimen is collected. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. 
 
 
 
 
 
  Therefore, we decided that the Plan does not have to pay for the testing (81479) provided on November 27, 
2021.
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 enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 has a past medical history of arthritis, hypertension lumbar spina stenosis, neuropathy, chronic obstructive pulmonary disease (COPD) and congestive 
heart failure and is living at home with weakness and functional decline. Medical problems are stable. There 
are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint. 
 
You asked the Plan to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint. You say that  The Plan denied your request. The Plan says based on Medicare 
guidelines, the facet joint injection(s), Injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint and additional levels you are requesting do not meet the requirements for approval. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve injection(s), diagnostic or therapeutic 
agent, paravertebral facet (zygapophyseal) joint. Our reviewer says that injection(s), diagnostic or therapeutic 
agent, paravertebral facet (zygapophyseal) joint are not medically necessary. Our physician reviewer found that 
based on the medical records provided there is no documentation that the requested repeat cervical facet 
injections at issue in this case meet Local Coverage Determination (LCD): Facet Joint Interventions for Pain 
Management - L38765 criteria for medically reasonable and necessary. Provided records do not document at 
least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) from 
the prior injections from October 14, 2021 as required by the LCD. Records indicate the enrollee had 50% 
improvement in pain symptoms for about one week. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) 
joint have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), 
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an inpatient hospital stay provided on 
December 21, 2021, to December 29, 2021 
 
You asked the Plan to waive the cost share for an inpatient hospital stay. You say that you say that you cannot 
afford this amount and would like a reconsideration. The Plan denied your request. The Plan says the cost share 
applied was correct. 
 
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 $360 per 
day for inpatient hospital care for days 1 to 5.  
 
You have been asked to pay $1800 for an inpatient hospital stay. You were hospitalized for 5 days ($360 x 5 
days = $1800). An inpatient hospital stay falls within the Inpatient Hospital Care 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 cost share for an inpatient hospital stay provided on December 21, 2021, to 
December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the compression stocking/sleeve identified with code 
A6549. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve the compression 
stocking/sleeve identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100.35 coinsurance for a knee brace provided on January 
27, 2022. 
 
You asked the Plan to waive the $100.35 coinsurance for a knee brace. You say that you should not have to pay 
this coinsurance because the knee brace didn't fit properly. The Plan denied your request. The Plan says you 
must pay a $100.35 for a knee brace. 
 
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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies.  
 
You have been asked to pay a $100.35 coinsurance for a knee brace. A knee brace falls within the Durable 
Medical Equipment (DME) and Related Supplies 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 
$100.35 coinsurance for a knee brace provided on January 27, 2022.