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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 19, 2022, to July 7, 
2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that medically necessary inpatient 
services were provided to the enrollee with the expectation that these services would be reimbursed 
accordingly. The Plan denied your request. The Plan says that there were no doctor notes for May 23, 2022, to 
July 7, 2022, included with the appeal. The Plan also says that these dates are not a covered benefit as only 13 
of the 49 days have doctor notes included with the appeal. 
 
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 the 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 enrollee was cleared for discharge on May 18, 2022, once hyperkalemia was 
corrected. However, the enrollee was never accepted back to the skilled nursing facility (SNF) due to elevated 
white blood cell counts. Our reviewer found that there were multiple discharge planning issues and 
requirements which included mechanical ventilation, hemodialysis, multiple drug resistant organism infections, 
and wound care. There were continued difficulties with the SNF accepting the enrollee back. Our physician 
reviewer also found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department 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 the acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from May 19, 2022, to July 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested supplies are medically 
necessary for the enrollee due to type 2 diabetes mellitus with hyperglycemia. The Plan denied your request. 
The Plan says the enrollee does not meet coverage criteria for the requested CGM and supplies. 
 
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, require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results or have had an in-person visit with their treating physician to assesses adherence to their 
CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for 
coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on June 15, 2022. 
 
You asked the Plan to waive the copayment for vision care. You say that you were told by the Plan that the 
copayment was going to be covered in full as you are a diabetic. 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 $20 
copayment for medical eye exam.  
 
You have been asked to pay $20 copayment for vision care. This item/service falls within the medical eye 
exam 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 vision care provided on June 15, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve medial branch blocks (MBBs) (64490, 64491, 64492). 
 
You asked the Plan to pre-approve MBBs. You say that this treatment is considered safe and effective. You 
also say that the enrollee has exhausted conservative treatments for more than 6 weeks in the past 6 months. 
The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all the criteria. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are medically necessary. Our physician reviewer found the provided documentation indicate 
the enrollee experiences moderate to severe pain that causes functional deficit. The reviewer found the enrollee 
has tried and failed 3 months of conservative therapy. The reviewer found there is an absence of untreated 
radiculopathy or neurogenic claudication. The reviewer also found that there is no non-facet pathology per 
clinical assessment that could explain the enrollee's pain. Therefore, the reviewer found that the requested 
MBBs are medically reasonable and necessary 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 MBBs have been met. Therefore, we decided that the Plan has to pre-approve 
medial branch blocks (MBBs) (64490, 64491, 64492).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve onabotulinumtoxina (Botox) (J0585). 
 
You asked the Plan to pre-approve Botox injections. You say that the enrollee is experiencing nausea and 
abdominal discomfort after eating. The Plan denied your request. The Plan says the requested drug is not 
medically necessary for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox injections. Our reviewer says 
that the requested Botox injections are not medically necessary. Our physician reviewer found Botox injections 
is not the standard of care for treatment of the enrollee's condition. The reviewer found that high quality 
evidence has not been consistently demonstrated in contemporary literature for long-term benefit, in treatment 
of the enrollee's purported gastroparesis. Therefore, the reviewer found that the requested Botox injections are 
not medically reasonable or necessary in the treatment of the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve onabotulinumtoxina (Botox) (J0585).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on June 02, 2022. 
 
You asked the Plan to waive the copayment for a mammogram. You say that you say you cannot afford to pay 
this. 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 $20.00 
copayment for basic imaging service. 
 
You have been asked to pay a $20.00 copayment for a mammogram. This item/service falls within the basic 
imaging service 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 mammogram 
provided on June 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires (A4557) and electrical stimulator supplies, 2 
leads, per month (A4595). 
 
You asked the Plan to pay for lead wires and electrical stimulator supplies. You say that you disagree with the 
denial and have submitted medical records for review. The Plan denied your request. The Plan says 
documentation submitted did not include a proof of delivery, or a delivery ticket. Per USPS tracking, it states 
label created, not yet in system which means there is no proof of delivery. 
 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 proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for lead wires (A4557) and electrical stimulator supplies, 2 leads, per 
month (A4595).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met 
and stabilized in the acute care setting and they are able to transfer to the LTACH. The Plan denied your 
request. The Plan says the LTACH services have not met the criteria for approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 12, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that your provider was directed to 
by the Plan to have you transferred to a rehabilitation facility. You say that you were not aware of the 
transportation cost and was not given an option to obtain alternate arrangements. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for ambulance services. This item/service falls within the 
ambulance services 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 ambulance services 
provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on March 26, 2019. 
 
You asked the Plan to pay for the physician service. You say that the claim should be reprocessed and paid. 
The Plan denied your request. The Plan says the enrollee's date of birth is not valid compared to what is in the 
Plan's system. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly, with the 
correct date of birth. 
 
We find that the services were not supported in the medical record. Specifically, the enrollee's date of birth was 
not entered correctly. Based on this information, we decided that Medicare rules for coverage of the physician 
service have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99213) 
provided on March 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
without contrast (72141). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 this service. Our reviewer says that this 
service is not medically necessary for the enrollee. Our physician reviewer found that in this case, the record 
indicates that the enrollee has fibromyalgia and chronic neck pain with radiculopathy. The record provided 
does not indicate that repeat plain films have been performed as the most recent studies do not demonstrate 
significant cervical disease. The record provided does not indicate the presence of red flag symptoms or 
abnormal neurological examination findings. The requested service is not medically necessary and reasonable 
for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the cervical spine without contrast (72141).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient minimally-invasive surgical (MIS) sacroiliac 
(SI) joint fusion. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MIS SI joint fusion is covered when 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of at least 75 
percent pain relief with prior injection therapy of the SI joint for this enrollee. The records do not support that 
the criteria for coverage are met. The requested inpatient procedure is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient minimally-invasive surgical (MIS) sacroiliac (SI) joint fusion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on July 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that this should be covered. The Plan denied your request. The 
Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an OON 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 lab work provided on 
July 5, 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 infusion supplies for external drug infusion pump, per 
cassette or bag (A4222) and a disposable drug delivery system (A4305). 
 
You asked the Plan to pre-approve infusion supplies and a disposable drug delivery system. You say that you 
are the only provider in the area offering expedited SC infusion. The enrollee is at risk for being hospitalized. 
The Plan denied your request. The Plan says durable medical equipment is an item that is medical in nature, 
prescribed by your provider, repeatedly used for a medical purpose in your home, and is not intended mainly to 
make things more convenient or comfortable. The item requested doesn't meet these requirements. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve infusion supplies for external drug infusion pump, per 
cassette or bag (A4222) and a disposable drug delivery system (A4305).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 6, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 6, 2022.