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

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided from 
April 9, 2021, to April 16, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that because your 
initial hospital admission was due to COVID-19, this coinsurance should be waived. The Plan denied your 
request. The Plan says you were charged this coinsurance 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 10% 
coinsurance for inpatient hospital care.  
 
You have been asked to pay 10% coinsurance for the inpatient hospital services. We looked at the medical records from this hospitalization.  While it shows that in March of this year you had COVID-19, there is no 
evidence in the medical records that you were treated for COVID-19 during the course of the hospitalization in 
question.  Your contract only waives your cost sharing if you are admitted to the hospital due to COVID-19.  
The medical records do not indicate that is the case. 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 coinsurance for 
inpatient hospital services provided from April 9, 2021, to April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81407, 
81479, 81405, 81406, 81286, 81403, 81408, 81404) provided on April 22, 2021. 
 
You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this was medically 
necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive 
cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive cardiovascular genetic panel (81407, 81479, 81405, 81406, 81286, 81403, 81408, 81404) 
provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies for the enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not receive at least 3 insulin 
injections per day. 
 
  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. 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 
Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services to be provided by an out-of-network provider 
on December 14, 2020, to December 17, 2020. 
 
You asked the Plan to pay for dental services. You say that these services should be paid for by the Plan. The 
Plan denied your request. The Plan says this provider opted out of Medicare from April 16, 2020, to January 
26, 2021. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services to be provided by an out-of-network provider on December 14, 2020, to December 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies and materials (99070) provided on 
December 4, 2020. 
 
You asked the Plan to pay for supplies and materials. You say that you were told the ambulance services would 
be covered due to Coronavirus. The Plan denied your request. The Plan says based on Medicare guidelines, the 
incorrectly coded supplies (99070), which represent non-emergency transportation to pick up your truck after a 
hospitalization that you and/or your provider is/are requesting does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 
We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 Therefore, we decided that the Plan does not have to pay for supplies and materials (99070) provided on 
December 4, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Euflexxa shoulder injections. 
 
You asked the Plan to pre-approve the Euflexxa shoulder injections. You say that you wish to have these 
treatments to avoid shoulder replacement surgery at this time. The Plan denied your request. The Plan says that 
the use of this agent for shoulder arthritis is not supported and not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the Euflexxa shoulder injections. Our 
reviewer says that the requested use of Euflexxa is considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a 45-year-old male with left shoulder pain related to osteoarthritis. 
Treatment with Euflexxa injections has been requested. Based on the medical records provided and the 
Medicare-approved major drug compendia (Micromedex/Drugdex) there is documentation that supports that 
the Euflexxa is medically reasonable and necessary for the patient. Micromedex/Drugdex contains a citation for 
an off-label, medically accepted indication for hyaluronic acid (such as Euflexxa) for shoulder arthropathy.  
 
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 Euflexxa shoulder injections have been met. Therefore, we decided that the 
Plan has to pre-approve Euflexxa shoulder injections.  
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot go home because the services you were 
offered were not enough. The Plan denied your request. The Plan says you do not require, nor could you 
actively participate in three hours per day, five days per week of intensive therapy. The Plan also says that you 
do not require an intensive and coordinated interdisciplinary approach to providing rehabilitation given your 
significant progress. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer 
also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight psychotropic testing provided on June 7, 
2021. 
 
You asked the Plan to pay for the testing services. You say that the test informs clinicians about which 
medications may require dose adjustments. The Plan denied your request. The Plan says the test has not been 
shown to be useful. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. In this case, there are insufficient records to show that testing was 
ordered based on the enrollee?s diagnosis, medical conditions, or other medications. The testing is not 
considered reasonable and necessary merely on the basis of a patient having a particular diagnosis. Unless the 
record reflects that the treating clinician has already considered non-genetic factors to make a preliminary drug 
selection, the testing is not considered reasonable and necessary. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneSight psychotropic testing provided on June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you will suffer financially if you have to 
continue making the monthly payments for the enrollee's room and board, plus additional medical costs. The 
Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that required the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair and delivery charge provided on May 24, 2021. 
 
You asked the Plan to pay for these services. You say that you needed this after your hip replacement surgery. 
The Plan denied your request. The Plan says that you did not receive these services from a Medicare certified 
provider. 
 
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who 
is not enrolled in the Medicare Program. 
 
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for the lift chair and delivery charge provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the MBBs. We decided that the Plan does not have to pre-approve 
MBBs at a third level.  
 
You asked the Plan to pre-approve the MBBs. The Plan says that the coverage criteria are not met. 
 
We decided that the Plan has to pre-approve MBBs at two levels bilaterally.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 MBBs. Our reviewer says that MBBs at two levels are medically reasonable and necessary. Our physician reviewer found that the LCD 
specifically limits utilization to two levels bilaterally. There is no explanation for the necessity of doing a third 
level at this session. Two levels bilaterally are medically reasonable and necessary and can be assessed for 
completeness of pain relief.  
 
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 MBBs have been met. Therefore, we decided that the Plan has to pre-
approve MBBs at two levels bilaterally.  
 
We also decided that the Plan does not have to pre-approve MBBs at a third level. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 at a third level. Our reviewer 
says that MBBs at two levels are medically reasonable and necessary. Our physician reviewer found that the 
LCD specifically limits utilization to two levels bilaterally. There is no explanation for the necessity of doing a 
third level at this session. Two levels bilaterally are medically reasonable and necessary and can be assessed for 
completeness of pain relief.  
 
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 at a third level have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MBBs at a third level. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a nasopharyngoscopy procedure. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
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 the procedure. Our reviewer says that 
the requested nasopharyngoscopy is considered medically reasonable and necessary in this case. Our physician 
reviewer found that a balloon device to treat Eustachian tube dysfunction was approved by the Food and Drug 
Administration in 2016. Recent systematic reviews by Froehlich et al. (2018) and Huisman et al. (2020) 
reported that balloon dilation of the Eustachian tube resulted in improvement in subjective and objective 
outcomes for patients with Eustachian tube dysfunction, and that complications were generally few, mild, and 
self-limited. The requested service meets medically reasonable and necessary criteria 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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve a nasopharyngoscopy procedure.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services (A0432) provided on June 28, 
2021. 
 
You asked the Plan to pay for paramedic intercept. You say that the ambulance transportation was medically 
necessary, and you did not have control over the paramedic situation. The Plan denied your request. The Plan 
says the paramedic intercept services were not rendered in a rural area as defined by Medicare. There is no 
contract between the two ambulance providers. The paramedic intercept claim was submitted appropriately as a 
separately payable service and medical records confirm these services took place. No payment can be made by 
the Plan as paramedic intercept services are not covered. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services (A0432) provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplemental nutritional drinks for the enrollee. 
 
You asked the Plan to pre-approve the drinks. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a need for a feeding tube for proper nutrition. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve supplemental nutritional drinks for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CPAP device (E0601) provided on January 29, 2021, by a 
provider not enrolled in the Medicare program. 
 
You asked the Plan to pay for a CPAP device. You say that the requested item is a medical necessity for you 
due to a global recall of the CPAP machine you were using previously. The Plan denied your request. The Plan 
says rules for payment have not been met because the supplier of the item at issue is not enrolled in the 
Medicare program. 
 
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. 
 
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 a CPAP device (E0601) provided on 
January 29, 2021, by a provider not enrolled in the Medicare program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and comprehensive oral 
evaluation (D0150) provided on July 26, 2021. 
 
You asked the Plan to pay for the x-ray and exam. You say that these are necessary services for the removal of 
a wisdom tooth and are not for a general exam. The Plan denied your request. The Plan says you previously 
had a complete series of full mouth x-rays and a comprehensive oral exam in May of 2021, which were 
covered by the Plan at that time. Your benefit limitations for these services were exceeded on the date in 
question, and therefore payment will not be made. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan?s dental benefit can 
cover one periodontal or comprehensive oral evaluation every three years and one complete series of full 
mouth x-rays or panoramic x-rays once every five years.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services are requested in a 
frequency that exceeds what is covered under this benefit. Documentation shows that you had a previous 
complete series of full mouth x-rays less than five years ago and a previous comprehensive oral exam less than 
three years ago. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and 
comprehensive oral evaluation (D0150) provided on July 26, 2021.