Persius/hicric huggingface dataset:
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 exceeds the criteria for an 
LTACH admission which is clearly demonstrated by the clinical information provided. You say that skilled 
nursing facility care will not give the enrollee the best opportunity to regain her baseline quality of life. The 
Plan denied your request. The Plan says admission to an LTACH is not to be used as an alternative to 
completion of the full course of treatment at the current 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 is more stable and should only require short-term additional acute care 
services that can safely be provided at the current facility. 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  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 laboratory services provided on July 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when there is pain 
that has been present for a minimum of three months with documented failure to respond to noninvasive 
conservative care management. 
 
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 facet joint injections. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no documentation of 
conservative therapy. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (64493, 64494, 64495).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty, right knee (27486). 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the total knee arthroplasty. Our 
reviewer says that the requested services are not medically necessary. Our physician reviewer found there are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty, right knee (27486).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 
1, 2022, to June 13, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you did not know that 
the Plan does not get 20 percent of any insurance and that it would not go towards any HMO plan. You also say 
that in the past with a previous Plan you paid 20 percent. 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 $275 
copayment per day, days 1-6. $0 copayment per day, days 7 to 90.  
 
You have been asked to pay a total of $1,650 ($275 x 6 days = $1,650). Inpatient hospital care falls within the 
inpatient hospital 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 inpatient 
hospital care provided from June 1, 2022, to June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services at a weight loss 
facility. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that this was covered under 
your previous plan. You say that you were told this plan has better coverage. You also say that it took you three 
months to get this appointment. The Plan denied your request. The Plan says medical nutrition therapy is not 
covered for weight loss. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services at a weight loss facility.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 18, 
2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that the Plan neglected to review your 
claim properly and sent an inaccurate denial of coverage. 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 $90 
copayment for in-network emergency care.  
 
You have been asked to pay $90 for emergency care. This item/service falls within the emergency 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 an emergency care provided on 
August 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy services provided on January 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for speech therapy services. You say that speech therapy services do not require 
authorization. The Plan denied your request. The Plan says the enrollee must receive care from a network 
provider. 
 
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 speech therapy services provided on January 25, 
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 rental of an electronic cancer treatment device for your 
glioblastoma multiforme (GBM), (a brain tumor/cancer). 
 
You asked the Plan to pre-approve tumor treatment field therapy (TTFT). You say that it is medically 
necessary. The enrollee was approved and covered for this tumor treating therapy since 1/3/2019 through the 
Plan for the device post recurrence. The Plan denied your request. The Plan says this is recurrent GBM after 
your initial treatment. 
 
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 tumor treatment field therapy (TTFT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of glioblastoma multiforme status-post 
resection followed by concurrent temodar/radiation with reoccurrence status post SRS now on Avastin. This 
tumor was initially diagnosed in 9/2/2018. On 3/5/19, she was started on Avastatin and on 3/13/19, she had 
SRS to posterior resection cavity. The enrollee was seen on 10/19/22 for a follow-up. According to the LCD, 
TTFT is denied for recurrent of GBM disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tumor treatment field therapy (TTFT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve rental of an electronic cancer treatment device for your glioblastoma 
multiforme (GBM), (a brain tumor/cancer).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service April 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that CPT code 81595 is not supported in the medical record. The case file shows that the testing was 
not ordered by the physician provided on the claim. There are insufficient medical records from the enrollees 
treating physician to show the testing was indicated. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
the lab testing billed for date of service April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and bilateral 
leg sleeves (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and bilateral leg sleeves. You say that you 
disagree with the denial. The Plan denied your request. The Plan says after a four-week trial of conservative 
therapy, there has been improvement in the lympedema and therefore, the requested PCD and accessories are 
denied. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
bilateral leg sleeves. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the suppled medical records do not adequately show trial and failure of trial of conservative therapy. The 
latest provided medical records from the enrollee's treating physician (08/29/2022) report the enrollee's 
lymphedema treatment has "helped his swelling significantly" and "continue daily compression stocking/wrap 
use" is reported in the treatment plan for this visit. The latest report from physical therapy of 10/26/2022 
reports "self-rated progress 80%, legs are maintaining in compression stockings" and "less pitting edema B 
lower legs" and "dc today with great prognosis to maintain his leg edema at the current state." Records also do 
not show good enrollee cooperation with compliant use of an appropriate compression bandage system or compression garment as required by the Local Coverage Determination (LCD): Pneumatic Compression 
Devices - L3382. The enrollee's compliance is rated as "fair" with use of a compression bandage system or 
compression garment. 
 
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 pneumatic compression device and bilateral leg sleeves have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and 
bilateral leg sleeves (E0667).
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 CGM is medically 
necessary due to type 2 diabetes mellitus with other specified complication. 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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the requested CGM should be 
covered. The Plan denied your request. The Plan says you do not meet coverage 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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a surgical procedure on March 17, 2022, and 
office visits provided on March 17, 2022, and April 4, 2022. 
 
You asked the Plan to waive the cost share the surgical procedure and office visits. You say that biopsy results 
should be paid by insurance. 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 $10 
copayment for in and out-of-network services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other non-physician health care professionals in a 
specialists office (as permitted by Medicare rules) after your $500 plan deductible. 
 
The record shows your deductible was not met prior to receiving services on March 17, 2022. The cost sharing 
amount for a surgical procedure on March 17, 2022, and office visits provided on March 17, 2022, and April 4, 
2022 was applied to your deductible. You have been asked to pay $10 copayment for the office visit on March 
17, 2022. 
 
DATE OF 
SERVICE 
 
SERVICE 
ALLOWED 
AMOUNT 
 
DEDUCTIBLE 
 
COPAYMENT 
 
COST SHARE 
March 17, 2022 99214 $130.00 $130.00  $130.00 
March 17, 2022 11602 $219.00 $189.20 $10.00 $199.20 
April 4, 2022 99213 $86.00 $86.00  $86.00 
TOTAL     $415.20 
 
These items/services fall within the physician/practitioner services, including doctors office visits 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 cost share for a surgical procedure on March 17, 2022, and 
office visits provided on March 17, 2022, and April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 12, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for a home visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 a home visit provided on July 12, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on August 3, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that the psychotherapy services were medically 
necessary. The Plan denied your request. The Plan says the psychotherapy services were not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for psychotherapy services. Our reviewer says 
that the requested psychotherapy services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that based on review of the records provided, this enrollee was not showing any 
symptoms of agitation, anxiety, social isolation or worry. She had no suicidal thoughts. The enrollee did not 
show any withdrawal. The enrollee was alert and responsive. Based on review of the records provided, this enrollee did not show any symptoms of her illness, which would require a visit or treatment. The visit was 
found not to be 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 psychotherapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for psychotherapy services provided on August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous electrical nerve stimulation (TENS) 
device (E0730), provided on May 17, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the item is medically necessary. The Plan denied 
your request. The Plan says Transcutaneous Electric Nerve Stimulation (TENS) units and garments 
and supplies for chronic back pain are not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the TENS device have not been met. Therefore, we decided that the Plan does 
not have to pay for the Transcutaneous electrical nerve stimulation (TENS) device (E0730), provided on May 
17, 2022.