Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 receiver and supplies. 
 
You asked the Plan to pre-approve the Dexcom G6 receiver and supplies. You say that the items are necessary. 
The Plan denied your request. The Plan says the Medicare rules 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 enrollee is not on insulin injections three (3) or more times daily 
and there is no evidence that the enrollee's blood glucose levels need frequent adjustment. Based on this 
information, we decided that Medicare rules for coverage of the Dexcom G6 receiver and supplies have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Dexcom G6 receiver and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine 
(E0601), provided on October 15, 2021. 
 
You asked the Plan to pay for a CPAP machine. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item was obtained through a supplier tha is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure 
(CPAP) machine (E0601), provided on October 15, 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 the enrollee needs to be transferred to 
long term acute care hospital instead of remaining in the current facility as they will require another 4-6 weeks 
in acute care for transitioning from acute illness. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and does not require transfer to a long-term acute care hospital. 
 
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 the enrollee was admitted to the acute care hospital with viral pneumonia, acute 
respiratory failure, sepsis and end-stage renal disease. The enrollee was treated with antibiotics, fluids, and 
oxygen. The enrollee appears to be more stable and improving and should only require short-term additional 
acute care services that can be safely administered at the current facility until appropriate for a lower level of 
care.  
 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 she is currently receiving 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is necessary. The Plan 
denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding any imaging evidence corroborating 
Modic changes at the requested operative level of L4-5. In this case, there were/are multiple plausible 
pathologic sources of significant pain generation. Overall, documentation was/is lacking regarding reasonably 
detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary 
generators of the enrollee's chronic persistent pain. Documentation does not support actual formal surgical 
ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the request for intracept intraosseous nerve ablation at 
L4-5 is not medically reasonable or 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 the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on July 20, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were rendered 
to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 20, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care 
(99223) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (code D6010), prefabricated 
abutment (code D6056) and implant supported porcelain/ceramic crown (code D6065) for tooth #2, #5, #7, 
#10, #12, #19 and #20. 
 
You asked the Plan to pre-approve implant placement, prefabricated abutment and implant supported 
porcelain/ceramic crown. You say that you need to have these services done as soon as possible. The Plan 
denied your request. The Plan says these services are not covered under your benefit plan. 
 
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 pre-approve 
implant placement (code D6010), prefabricated abutment (code D6056) and implant supported 
porcelain/ceramic crown (code D6065) for tooth #2, #5, #7, #10, #12, #19 and #20.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of intrauterine device (IUD) (58300) and 
elvonorgestrel-releasing intrauterine contraceptive system (J7297), provided on October 18, 2021. 
 
You asked the Plan to pay for the IUD insertion. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the IUD insertion have not been met. Therefore, we decided that the Plan does not have to pay for 
the insertion of intrauterine device (IUD) (58300) and elvonorgestrel-releasing intrauterine contraceptive 
system (J7297), provided on October 18, 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 the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can be safely administered at the current facility until the enrollee is 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 
17, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the procedure was rendered in the appropriate place of 
service. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue lists a place of service as an outpatient hospital. 
However, the records show that the enrollee was receiving inpatient care at the time the services were provided.  Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on 
January 17, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on April 25, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was only seen one time. The 
Plan denied your request. The Plan says that the procedure exceeds the maximum number of services allowed 
under guidelines for a single date of service. 
 
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. 
 
We looked at the file and the rules. The records show that the enrollee presented to the emergency room with 
intermittent chest pain, edema, and shortness of breath. The records do not show that the enrollee was seen on 
more than one occasion on the date of service at issue. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that 
the Plan has to pay for the emergency room services provided on April 25, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the tendon sheath incision (26055), 
provided on December 17, 2021. 
 
You asked the Plan to waive the copayment for the tendon sheath incision. You say that the service should be 
covered. The Plan denied your request. The Plan says the cost share was applied 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 $360 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $360 copayment for the tendon sheath incision. This service falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 copayment for the tendon sheath 
incision (26055), provided on December 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided form May 23, 2021, through 
May 26, 2021, at DRG 246. 
 
You asked the Plan to pay for the inpatient services at DRG 246. You say that the physician made a diagnosis 
of acute kidney injury with acute tubular necrosis based on clinical findings, so the secondary diagnosis was 
appropriately coded. You say that the denial should be overturned, and payment approved at the originally 
billed DRG 246. The Plan denied your request. The Plan says the documentation does not support the diagnosis 
of acute tubular necrosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code N17.0, defined as acute kidney 
failure with tubular necrosis. 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 inpatient 
services at DRG 246. Our reviewer says that the documentation does not support the secondary diagnosis code 
N17.0. Our physician reviewer found there was no nephrology consult and no documentation of oliguria or 
anuria. There were also no lab abnormalities in the collected urinalysis documented by the physician to support 
the diagnosis of acute tubular necrosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided form May 23, 2021, through May 26, 2021, at DRG 246.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aero T Aluminum ultralight weight wheelchair and 
accessories to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says there is no medical necessity for specific brand Aero T Aluminum ultralight weight 
wheelchair at this time. 
 
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. 
 
 There is no medical necessity for specific brand, Aero T Aluminum ultralight weight wheelchair and 
accessories at this time. If DME serves the same purpose as equipment already available to the member, then it 
is not considered reasonable and necessary. Furthermore, 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 Aero T Aluminum ultralight weight wheelchair and 
accessories to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on January 14, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the patient had multiple exams on this date of 
service and the reports support the level of service. You say that the claim should be reconsidered for 
processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code 
edit. 
 
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 code 70450 
is a column II code to column I code 70496. 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. Therefore, we 
decided that the Plan does not have to pay for the CT scan (70450) provided on January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kidney transplant (CPT code 50360 x 2). 
 
You asked the Plan to pre-approve kidney transplant. You say that the enrollee meets the criteria for a kidney 
transplant. The Plan denied your request. The Plan says they did not get the supporting documents that clears 
you to be a candidate for kidney transplant. 
 
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 kidney transplant. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the services are not medically reasonable and necessary at this time. A kidney 
transplant requires a creatinine greater than 8.0 (or greater than 6.0 if you are a diabetic and symptomatic) 
and/or glomerular filtration rate (GFR) greater than 15 and lack of contraindications to transplant. These 
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 kidney transplant have not been met.  
 
  
Therefore, we decided that the Plan does not have to pre-approve kidney transplant (CPT code 50360 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies billed for services on 
January 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the supplies are appropriate for effective 
treatment. The Plan denied your request. The Plan says the claim processed correctly. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the electrical stimulator supplies billed for services on January 8, 2022.