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

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 spinal cord stimulator trial. Our reviewer says that the services are not medically necessary. Our physician reviewer found no psychological 
clearance documented. Spinal stenosis is not an evidence-based indication for a SCS trial. The request 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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 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 August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the longer you go without rehabilitation, the more 
damage to your level of self-care there is. The Plan denied your request. The Plan says that the denial of 
authorization for IRF care is correct. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that you have multiple active comorbidities including Parkinson's Disease 
and would require close medical supervision in an inpatient setting. Evaluating therapists state that you would 
benefit from intensive therapy in an IRF and would tolerate intense rehabilitation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
27, 2021, to July 19, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP claim 
was not submitted for these dates of service until September 16, 2021. This means this was submitted past the 
five day limit of the start of services. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from May 27, 2021, to July 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from February 4, 2022, to  
February 11, 2022. 
 
You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says that under 
federal regulations, the Medicare Advantage plan is prohibited from paying claims for care provided to our 
Medicare Advantage Plan members by a provider or Group Practice who have been precluded from 
participation in Medicare at the time services were rendered. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided us with proof that this provider is the provider on the 
exclusion list. Therefore, we decided that the Plan has to pay for inpatient hospital care provided from  
February 4, 2022, to February 11, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 6, 
2021, to September 7, 2021. 
 
You asked the Plan to pay for the inpatient post-stabilization care. You say that the services were medically 
necessary. You also say that the services were provided in good faith. The Plan denied your request. The Plan 
says there was no attempt to contact either the medical group or the health plan to request prior authorization to 
admit for post stabilization care. The Plan also says there was no documentation indicating the enrollee was 
unstable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our 
reviewer says that the post-stabilization care in an out of network facility was not medically necessary. Our 
physician reviewer found that the treating physician did not document that the patient was not stable for 
transfer on any dates of service. The reviewer also found that the provided documentation indicates that the 
enrollee was stable after the completion of the Emergency Department evaluation at 19:53 on September 6, 
2021, to transfer by ambulance to an in-network hospital. 
 
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 inpatient post-stabilization care have not been met. Therefore, we decided 
that the Plan does not have to pay for the acute inpatient hospital care provided from September 6, 2021, to 
September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate or other fiber gelling dressing (A6196) provided 
on March 17, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that this enrollee has been treated for their 
wound and billing separately for these supplies is appropriate. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 alginate or other fiber gelling dressing 
(A6196) provided on March 17, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 1, 2022, to 
March 4, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the admission and services were 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. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 1, 2022, to March 4, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with lesion removal 
performed on April 8, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you should not be responsible 
for the copayment. 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 $300 
copayment for outpatient hospital or ambulatory surgical center visits.  
 
The file shows that the procedure was performed due to a history of polyps. For this reason, the procedure is 
considered diagnostic instead of screening. Therefore, you have been asked to pay a $300 copayment for the 
colonoscopy. The colonoscopy falls within the Outpatient Surgery, Including 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 a colonoscopy with lesion removal performed on April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on March 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. The 
records provided for review do not show that the laboratory work was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on March 23, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this device has been embraced and 
recommended by clinicians and guidelines. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because studies have not proven that this is helpful for 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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is not known to be effective based on scientific evidence, professional 
standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence int he literature that the MyoPro 
orthosis will improve long-term outcomes for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections (96372) of vitamin B12 (J3420) 
provided from September 29, 2021, to February 23, 2022. 
 
You asked the Plan to waive the copayment for vitamin B12 injections. You say that the claim should be 
processed with a 10% coinsurance instead of a copayment. You say the services were rendered to you by a 
nurse rather than a physician and therefore the copayment for Part B drug administered by a physician does 
not apply. The Plan denied your request. The Plan says the cost-share was applied correctly as a copayment 
because the claims were submitted by a physician.   
 
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 
copayment for Medicare Part B prescription drugs administered by a primary care provider in 2021. Your 
contract with the Plan for 2022 clearly says that you must pay a $10 copayment for Medicare Part B 
prescription drugs administered by a primary care provider. 
 You have been asked to pay a total copayment of $130.23 for vitamin B12 injections. Vitamin B12 injections 
fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. The contract clearly states the cost-share for these 
services is $20 for services received in 2021 and $10 for services received in 2022. For each date of service, 
you were charged less than these normal copayment amounts. This means you are responsible for the lesser 
amount. 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 injections (96372) of vitamin 
B12 (J3420) provided from September 29, 2021, to February 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, non-
emergency transport, level 1 (A0426-HH) and ground mileage (A0425-HH) provided January 30, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transport and ground mileage. You say that there 
were no beds available for the enrollee to be admitted to and therefore needed transport to another hospital for 
inpatient care. The Plan denied your request. The Plan says this service is not separately payable because you 
were inpatient at the time of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider. This movement of the patient is 
considered "patient transportation" and is covered as an inpatient hospital service.  
 
We looked at the file and Medicare rules. Specifically, the record shows that the enrollee was admitted as 
inpatient to the origin location provider. The record also shows that the enrollee was moved to another provider 
while maintaining inpatient status with the original provider. This means that the ambulance service is covered 
as an inpatient hospital service and is not separately billable. Based on this information, we decided that Medicare rules for coverage of the non-emergency ambulance transport and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, non-
emergency transport, level 1 (A0426-HH) and ground mileage (A0425-HH) provided January 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities provided by a chiropractor from July 5, 
2021, to July 22, 2021. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would think the plan would base its 
decision on the provider's credentials and treatment regimen, and not on the inner workings of the Medicare 
system. The Plan denied your request. The Plan says these services were provided by a chiropractor and only 
manual manipulation of the spine for the treatment of subluxation is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic activities provided by a chiropractor from July 5, 2021, to July 22, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) to replace your present wheelchair. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested item 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
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 Group 3 power wheelchair. Our 
reviewer says that that a replacement power wheelchair is not medically reasonable and necessary in this case. 
Our physician reviewer found that you have a neurologic disorder with functional deficits. Criteria for a power 
wheelchair are met; however, there is no documentation that supports a new power wheelchair as opposed to a 
repair of the currently used power wheelchair is medically 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 a Group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 standard power wheelchair with single power option (K0856) to 
replace your present wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at-home COVID-19 test received on January 23, 2022. 
 
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The 
Plan says this cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that at-home COVID tests were covered by Medicare 
starting April 4, 2022. 
 
The test was received before the applicable Medicare benefit was implemented. Based on this information, we 
decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan 
does not have to pay for an at-home COVID-19 test received on January 23, 2022.