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

 
We decided that the Plan has to pre-approve acute inpatient hospital admission and care. 
 
You asked the Plan to pre-approve acute inpatient hospital admission and care. You say that the requested 
inpatient admission and care are a medical necessity for you. The Plan denied your request. The Plan says that 
the request is not medically necessary. 
 
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. 
 
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 acute inpatient hospital admission and 
care. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that the enrollee would be expected to be hospitalized for a period of 5 to 7 
days in duration. This would satisfy the requirement that the "admitting physician would reasonably expect that 
the patient's necessary hospital care (including earlier ED and/or observation care) will span two 
midnights." As the two-midnight threshold would be met, the request meets Medicare criteria for inpatient 
admission. 
 
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 admission and care have been met. Therefore, we 
decided that the Plan has to pre-approve acute inpatient hospital admission and care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D and 3D photographic facial images (D0350 and
D0351) provided on December 10, 2021.
You asked the Plan to pay for the 2D and 3D photographic imaging. You say that you would like
reconsideration because you did not request the imaging services and were not given the opportunity to deny
treatment. The Plan denied your request. The Plan says that these are not covered benefits under your plan.
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.
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. We find that though these services were provided by a Plan provider,
your Evidence of Coverage clearly does not indicate these services are covered benefits. Therefore, we decided
that the Plan does not have to pay for the 2D and 3D photographic facial images (D0350 and D0351) provided
on December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services and Part B
drugs provided on October 13, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy services and Part B drugs. You say that you
have never had a bill this high for your infusions. 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 a 20%
coinsurance for Medicare Part B Covered Drugs and Chemotherapy Drugs and the administration for these
drugs.
You have been asked to pay a 20% coinsurance for the chemotherapy services and Part B drugs. The Part B
drugs are not bundled with the chemotherapy services. This item/service falls within the Medicare Part B
Covered Drugs and Chemotherapy 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 the chemotherapy services and Part B drugs provided on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that you feel the services should be covered 
because you have severe pain with weight bearing and ambulating and you find it hard to perform activities of 
daily living. The Plan denied your request. The Plan says there is no signed physician order or supporting 
clinical documentation provided for the requested scooter. 
 
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 the power scooter have been met. 
There is no signed physician order and clinical records to support the requested scooter was not provided. The 
Plan also verified with the provider that they did not write an order for the requested scooter. The Plan made 
multiple attempts to obtain this information without success. Therefore, we decided that the Plan does not have 
to pre-approve the power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Caris Molecular Intelligence tumor testing provided on 
April 19, 2022. 
 
You asked the Plan to pay for the Caris Molecular Intelligence tumor testing. You say that the Caris Molecular 
Intelligence tumor testing provided on April 19, 2022, was medically necessary. The Plan denied your request. 
The Plan says the Caris Molecular Intelligence tumor testing provided on April 19, 2022, was not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Caris Molecular Intelligence tumor 
testing. Our reviewer says that the Caris Molecular Intelligence (MI) tumor testing provided on April 19, 2022, 
was not medically necessary. Our physician reviewer found the enrollee has a diagnosis of extensive small cell 
lung cancer. The coverage criteria as established by NCD 90.2 have not been met in this case, as the laboratory 
test does not have FDA approval or clearance as a companion in vitro diagnostic, and an FDA-approved or 
cleared indication for use in the enrollee's cancer. The available documentation does not support that the Caris 
MI Profile was medically reasonable and necessary for the enrollee in this case. 
 
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 Caris Molecular Intelligence tumor testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Caris Molecular Intelligence tumor testing provided on April 
19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has poor glycemic control. 
The Plan denied your request. The Plan says the enrollee is not eligible for coverage. 
 
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 does not indicate that the enrollee uses 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 requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for percutaneous transluminal coronary angioplasty (procedure 
code 92920) provided to the enrollee on October 27, 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 the denied code remains not supported. 
 
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 92920 is "Percutaneous transluminal coronary 
angioplasty; single major coronary artery or branch." 
 
We asked our coder 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 services at issue in 
this case were not supported by the medical records. Our reviewer found a review of the documentation, 
including operative note, fails to confirm that the cardiac interventionalist performed the elements of the 
procedure in question. Thus, fulfillment of the code cannot be independently verified. In summary, there is 
insufficient documentation to support the approval of procedure code 92920 in the clinical management of this patient. 
 
We looked at this coder'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 percutaneous transluminal coronary angioplasty (procedure code 92920) provided to the 
enrollee on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker with a seat. 
 
You asked the Plan to pre-approve the requested walker. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that walkers are only covered under certain medical 
indications. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee has a weight of more than 
300 pounds. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker with a seat.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bronchoscopy services provided on September 26, 2021. 
 
You asked the Plan to pay for bronchoscopy. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says these codes are not supported by the medical records. 
 
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 31645 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial. The CPT 
Code Manual definition of code 31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, 
when performed; with bronchial alveolar lavage. 
 
We asked our coder 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 bronchoscopy. Our reviewer says that these codes do not 
meet criteria for payment. Our reviewer found the general procedure note documents a procedure name of 
"pulmonary hygiene bronchoscopy for an indication of left lung atelactasis." It is documented that several 
aliquots of saline were given without success. Mucomyst through the scope was given with some improvement. The procedure notes do not document therapeutic aspiration of tracheobrinchial tree or bronchial alveolar 
lavage. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bronchoscopy have not been met. Therefore, we decided that the Plan does not 
have to pay for bronchoscopy services provided on September 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on October 12, 2021.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that the documentation does not support the
22 classes 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, we find that CPT code G0483 is not supported in the medical record. Specifically, the lab result
report does not show that 22 or more drug classes were tested for. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services (G0483) provided on October 12, 2021.
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 this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria 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 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 pre-approve an in-network benefit exception for physician's services 
to be provided by the requested out-of-network providers. 
 
You asked the Plan to pre-approve an in-network benefit exception for physician's services to be provided by 
the requested out-if-network providers. You say that you have been diagnosed with esophageal and liver 
cancer. The Plan denied your request. The Plan says in-network tertiary cancer center medical oncology 
specialist options and tertiary cancer center options in a similar geography from the member s residence have 
not been exhausted. 
 
The contract with the Plan says that you can receive your care from either a network provider or an out-of-
network provider. If you use an out-of-network provider, your share of the costs for your covered 
services may be higher. 
 
The requested providers in this case are not network providers with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services as an in-network benefit exception. Therefore, we decided that the Plan does not have to pre-approve an in-network benefit exception for physician's services to be provided by the 
requested out-of-network providers.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 4, 2021.
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 you are appealing the denial for 
preauthorization for select LTACH. The Plan denied your request. The Plan says the criteria was not met and 
the request is not medically necessary. The Plan will continue to cover the acute and critical care at the current 
facility until the enrollee's condition is stable for transfer. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
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 they are 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: 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 the enrollee requires physical therapy and 
occupational therapy to work on increasing strength. The Plan denied your request. The Plan says an IRF is not 
medically necessary, and the enrollee's needs can be met in an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
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 compression 
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your bottom dentures were burned in a 
total loss house fire. You say that you are not able eat without your bottom teeth and are lacking a nutritional 
diet for not having the ability to chew food. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 15, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).