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

 
We decided that the Plan does not have to pre-approve a heavy duty hospital bed (E0301). 
 
You asked the Plan to pre-approve the heavy duty hospital bed. You say that the bed is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 heavy duty hospital bed. Our 
reviewer says that a hospital bed is not medically necessary. Our physician reviewer found the record shows 
that the enrollee has limited mobility using a walker and does not show any problems with transfers.  
 
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 heavy duty hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a heavy duty hospital bed (E0301).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM. 
 
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 use insulin 
with at least three daily injections and does not 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 a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve SI joint RFA. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this procedure is 
experimental/investigational. 
 
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 SI joint RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found sacral lateral nerve branch blocks for the diagnosis and/or treatment of sacroiliac joint mediated 
pain are considered experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional imaging services (procedure code 74018) provided to the 
enrollee on May 26, 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 that there is no additional documentation supporting an additional study which was billed and 
remains denied. 
 
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 74018 is "Radiologic examination, abdomen." 
 
We find that an additional unit of CPT code 74018 is supported in the medical record. Specifically, the records 
contain reports from two different abdominal x-rays. There are two different rendering providers, and two 
different referring providers. The impression on each report is different, and it is clear that two different 
separate and distinct services were rendered. They are not a duplicate of each other. Based on this information, 
we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan 
has to pay for additional imaging services (procedure code 74018) provided to the enrollee on May 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 11, 2021. 
 
You asked the Plan to pay for the services provided. You say that the test aids in the diagnosis of bladder 
cancer. The Plan denied your request. The Plan says the testing was not approved by the ordering provider. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The case file shows that there is no record of the physician on file ordering 
the testing at issue. There are insufficient medical records to show the physicians intent for the test to be 
performed. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483). 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief . 
 
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 epidural steroid injections. Our 
reviewer says that the injections are not medically necessary. Our physician reviewer found there is no 
documentation of how much pain relief was obtained from the previous injections. 
 
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 epidural steroid injections have not been met. 
 
 
 
 
  
 
 
 Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (64483).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing therapy can safely be done at a lower 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. You 
are medically stable and do not need physical medicine and rehabilitation physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. While you may benefit from physical, speech and occupational therapy, at contact guard assist level 
for mobility and activities of daily living, you do not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Your rehab 
can be safely provided at a lower intensity and alternate setting in in-home with therapy. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
November 11, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were scheduled at 
the wrong location for a mammogram and fell outside on your way into the appointment. You also say that you 
went to the ER later that night and should not have to pay a copayment because you would not have fallen if 
you were scheduled at the correct location. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $90 
copayment for an emergency room visit.  
 You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency 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 copayment for an 
emergency room (ER) visit provided on November 11, 2021.  
 
Your complaint about being scheduled at the wrong location is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
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. The Plan denied your request. The Plan says the requested 
services are not reasonable and necessary. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that there is not a reasonable expectation that this patient 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional home health visits.  
You asked the Plan to pre-approve home health visits. You say that you are not able to change your dressing on 
your own. You also say that you cannot afford to drive to the clinic every day to have the dressing changed. 
The Plan denied your request. The Plan says the requested home health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health visits. Our reviewer says 
that the requested home health visits are not medically reasonable or necessary. Our physician reviewer found 
the provided documentation does not indicate that you are home bound, as evidenced by your ability to attend 
office appointments. The provided documentation does not include information indicating a description or 
picture of your wound. The provided records do not include your exact wound care needs are not actually 
described or ordered. There is no documentation of a lack of a willing or capable caregiver is not documented. 
The reviewer found that the services are being requested on a daily basis, while home health services must be 
intermittent. As such, the requested home health services for daily wound care are not shown to be medically 
necessary, reasonable or coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 30 additional home health visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that you were compliant with the regulations for 
billing. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim billed a place of service as 81, an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the enrollees sample was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 testing provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) 
provided on July 6, 2021. 
 
  You asked the Plan to pay for the targeted genomic sequence analysis panel (0242U). You say that there is a 
misinterpretation of the guidelines and billing Place of Service 81 is accurate. You say that the test is not 
considered an outpatient hospital service and the service should be paid. The Plan denied your request. The 
Plan says the place of service must reflect the location of the patient when the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 targeted genomic sequence analysis panel (0242U) 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 the targeted genomic sequence analysis 
panel (0242U) provided on July 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that inpatient skilled nursing facility care is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of inpatient skilled nursing facility care. 
 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 continued SNF care. Our reviewer says 
that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that based 
on the medical records provided there is no documentation that indicates daily skilled services are required. As 
of February 23, 2021 the enrollee was walking household distances with a wheeled walker with contact guard 
assistance and was a stand-by assist/supervision for transfers. Additionally, as a practical matter there is no 
documentation provided that indicates the enrollee requires the services on an inpatient basis, only in a skilled 
nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time 
basis appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that specimens are sent to the facility by the 
primary physician. The Plan denied your request. The Plan says the documents do not support the services 
billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim billed a place of service as an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on March 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound of the veins provided on 
September 3, 2021. 
 
You asked the Plan to reduce the copayment for an ultrasound of the veins. You say that you feel the insurance 
company should pay for a major portion of the balance for this service. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $155 
copayment for radiological diagnostic services, including ultrasounds in a physicians office.  
 
 You have been asked to pay $93.57, which is less than the $155 copayment for an ultrasound of the veins. An 
ultrasound of the veins falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 reduce the copayment for an ultrasound of the veins 
provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 8, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship 
between the enrollee and ordering physician. 
 
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 office visit (99202) provided on 
February 8, 2021. have been met. Specifically, the documentation submitted does not include sufficient clinical 
information to verify that CPT code 99202 was rendered on the billed date of service. Additionally, there is no 
evidence of an established relationship between the enrollee and provider.. Therefore, we decided that the Plan 
does not have to pay for the office visit (99202) provided on February 8, 2021.