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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital, and there are no issues for which 
LTACH may offer a therapeutic advantage. 
 
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 that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by Plan. The Plan has approved ongoing care in the current acute care setting. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the medical eye exam and the refraction provided on 
March 31, 2022. 
 
You asked the Plan to pay more for the medical eye exam and the refraction. You say that you were told the 
provider was in-network, and you should not be charged $80. You say you were told the exam would be $0. 
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 $30 
copayment for Level 1 physician services to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $30 copayment for the medical eye exam. The medical eye exam falls within the 
vision 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.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when done as a part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay more for the medical eye exam and the refraction 
provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says that the criteria for eligibility have not been met. 
 
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. Specifically, the plan did not send us medical records. You say that you should 
be eligible for SSBCI benefits due to your health issues. Without medical records, we cannot determine 
whether or not you are eligible for the benefits. Therefore, the Plan has not shown that their decision to deny 
the benefit is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-
approve the SSBCI benefits. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 16, 2022, to 
December 20, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary and should 
be covered. We should be in-network. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
services provided on December 16, 2022, to December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a bone replacement graft 
(D4263), a guided tissue regeneration (D4266), and osseous surgery (D4260), provided on December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0140 was exhausted on date of service June 14, 2022. D4263, D4266, and D4260 are 
not covered benefits. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), a bone replacement graft (D4263), a guided tissue regeneration (D4266), and osseous surgery 
(D4260), provided on December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment battery backup provided on 
July 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that you need a device that works during power 
loss. The Plan denied your request. The Plan says the provider is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment battery 
backup provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted, there is no documentation that you meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 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 SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records, we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM), supplies and 
accessories. 
 
You asked the Plan to pre-approve the CGM, supplies and accessories. You say that if this service is 
unnecessary why did your previous insurance plan covered this service. The Plan denied your request. The Plan 
says you do not require insulin three or more times daily. 
 
 
 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM, 
supplies and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM), supplies and accessories.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for osteotomy of spine, posterior or posterolateral approach, 1 vertebral 
segment; each additional vertebral segment rendered on October 11, 2022. 
 
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 the records 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 CPT code. In this case, the CPT Code Manual definition of 
code 22216 is "Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional 
vertebral segment (List separately in addition to primary procedure)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the ddescription of the procedure 
cites osteotomy was undertaken of the facet joints with a 12-inch curved osteotome, removing huge osteophytes 
at the facet joints at the L4-5 and L5-S1 bilaterally...The Misonix was used to osteotomize L4, L5, and S1. 
Inferior facets were removed bilaterally at L4 and L5 and then osteotomized the residual at lamina of L4, L5, 
and S1 with a Misonix bone cutter. The laminectomy was widened and the osteotomies at L4, L5, and S1 doing 
the Ponte osteotomies bilaterally at L4-5 foramen and L5-S1 foramen freeing up the nerve roots as well. The 
laminectomy was widened bilaterally as well as the superior inferior L4-S1. Therefore, the records do support 
that CPT 22216: osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment, each additional 
vertebral segment (list separately in addition to primary procedure) was rendered in this case.  
 
We looked at this coder's review, the file, and Medicare rules. 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 
osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment 
rendered on October 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you have a bulging disc in your 
neck, and it is not something that can be fixed by taking Tylenol. You say that the disc is very close to your 
spine, and you were informed by your doctor that physical therapy would put you at risk for severing the spine 
by the disc. The Plan denied your request. The Plan says the requested epidural steroid injection does not meet 
the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not medically necessary. Our physician reviewer 
found that the Medicare LCD criteria requires radicular pain, spinal stenosis or post-operative scaring. There is 
no indication that these are present here. The request is deemed not medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on September 9, 2021, to 
September 13, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, described as acute 
respiratory failure with hypoxia. 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 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found the enrollee presented with shortness of breath. This was attributed to 
congestive heard failure, in the setting of lung metastases and a small pleural effusion. There is no evidence 
that the enrollee had a separate and distinct diagnosis of respiratory failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 9, 2021, to September 13, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on July 6, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that this is medically necessary. The Plan denied your 
request. The Plan says that multiple billings of code 77371 is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a resected and 2 in-tact brain metastases and was planned to receive standard of 
care stereotactic radiosurgery (SRS) with each target treated with a single fraction of SRS on separate days. 
The treatment itself is the standard of 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 SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic body radiation therapy (SBRT).  
 
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 Freestyle Libre 14 day Sensor Kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 14 day Sensor Kit. You say that the enrollee needs close 
monitoring of her blood glucose levels to ensure improvement. You also say that the Freestyle Libre system 
allows for more comfortable and convenient glucose checks. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily.  
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, 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 the Freestyle Libre 14 day Sensor Kit have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 14 day Sensor Kit.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the nuclear stress test and the 
echocardiogram performed by an in-network provider on November 8, 2022. 
 
You asked the Plan to waive the cost sharing for the stress test and the echocardiogram. You say that you do 
not agree with the cost sharing. 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 each in-network covered diagnostic procedure or test at a network outpatient facility, and a 20% 
coinsurance for in-network covered diagnostic radiology services in the outpatient department of a network 
hospital or facility. 
 
You have been asked to pay a $90 copayment for the stress test. You have also been asked to pay a $291.62 
coinsurance for the echocardiogram ($1458.10 allowed amount x .20 = $291.62). These items/services fall 
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 waive the cost sharing for the nuclear stress test and the echocardiogram performed by an in-
network provider on November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed. 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.