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

 
We decided that the Plan does not have to waive the cost share for an inpatient hospital stay provided from 
January 1, 2022, to January 29, 2022. 
 
You asked the Plan to waive the cost share for the inpatient hospital stay. You say that your stay was due to the 
skilled nursing facility had no availability. 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). The contract with the Plan clearly says that you must pay a $275 copayment, after your $4,000 plan deductible, for an in-network hospital stay per days 1-5 (per Medicare-
covered stay), which includes day of admission and day of discharge. After the 5th day, the Plan pays 100 
percent of the covered expenses. 
 
The record shows you had met $3,276.93 out of your $4,000.00 in-network deductible when the claim was 
received on March 10, 2022. The cost sharing amount for the inpatient hospital stay was applied to your 
deductible. You have been asked to pay $791.93 ($4,000.00 - $3,276.93 = $791.93). The inpatient hospital stay 
falls under 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 cost share for an 
inpatient hospital stay provided from January 1, 2022, to January 29, 2022.  
 
Your complaint about getting yelled at to sign the paperwork is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that you have had this procedure done a couple times in the 
past. The Plan denied your request. The Plan says the requested injection 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 RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of 
sacroiliac joint mediated pain is considered experimental and investigational. Therefore, the reviewer found 
that the requested RFA is not 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1851) provided May 31, 2022. 
 
You asked the Plan to pay for the orthosis. You say that please review claim denial for accuracy. The Plan 
denied your request. The Plan says diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. We looked at this the file, and Medicare rules. The claim was 
billed with diagnosis code M25.562 - pain in left knee. Medicare rules says that claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary if only pain or a 
subjective description of joint instability is documented. Based on this information, we decided that Medicare 
rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay 
for the knee orthosis (L1851) provided May 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ostomy supplies rendered on September 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the enrollee was on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ostomy supplies rendered on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 19, 
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 the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and investigational. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or 
double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated 
(L8702) is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k). 
At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's 
medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional 
treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional 
muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary 
for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and 
expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visit (90832) provided on August 8, 2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that this should be covered. The Plan denied 
your request. The Plan says the 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 pay for the psychotherapy service. Our reviewer 
says that the psychotherapy services was not medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation does not indicate that the enrollee was not showing any symptoms 
of anhedonia, withdrawal or hopelessness. The enrollee had no suicidal thoughts. The enrollee was alert and 
responsive. The provided documentation does not indicate that the enrollee was showing any symptoms of their 
illness which would require a visit or treatment. Therefore, the reviewer found that the psychotherapy service was not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the psychotherapy service have not been met. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy visit (90832) provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483). 
 
You asked the Plan to pre-approve a repeat TFESI. You say that the enrollee has done physical therapy, 
Tylenol, and previous injection. You also say that the requested injection is medically necessary. The Plan 
denied your request. The Plan says a repeat TFESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat TFESI. Our reviewer says that 
a repeat TFESI is not medically necessary. Our physician reviewer found the provided documentation indicates 
that the previous TFESI was performed on September 7, 2022. The reviewer found there is no documentation 
of at least 50% of sustained improvement in pain relief and/or improvement in function measured from 
baseline using the same scale for at least 3 months. Therefore, the reviewer found that a repeat TFESI is not 
medically necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toilet seat with low back support. 
 
You asked the Plan to pre-approve a toilet seat. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
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 a toilet seat with low back support.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attended polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve an attended PSG. The Plan denied your request. The Plan says a PSG for the 
diagnosis of sleep apnea is to be established by a home study in people without severe lung disease, serious 
neuromuscular disease, severe heart failure, or strong suspicion of a complex sleep disorder (such as 
narcolepsy). The Plan also says that the enrollee does not have these conditions, and does not qualify for a 
sleep-lab test. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic testing is covered only if the patient has 
the symptoms of obstructive sleep apnea, narcolepsy, impotence, or parasomnia.  
 
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 attended PSG. Our reviewer says 
that an attended PSG split night with positive airway pressure titration is not medically necessary. Our 
physician reviewer found this enrollee has chronic fatigue. The medical records do not include a complete sleep 
history, Epworth score, evaluation of upper airway patency, or neck circumference. Our reviewer found that 
there is no history suspicious for parasomnias or other sleep disorders. Our physician reviewer also found that 
the enrollee does not have conditions that would make a home PSG unsafe or inappropriate.  
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 attended PSG have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an attended polysomnography (PSG) (95811).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve a TTE. You say that you believe the enrollee should have another 
echocardiography to evaluate the progression of left ventricular systolic dysfunction. The Plan denied your 
request. The Plan says the requested service is not reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the evaluation of LV function with prior ventricular 
function within the past year in patients in whom there has been no change in clinical status is not deemed to be 
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 a TTE. Our physician reviewer found at 
issue is the medical necessity of a repeat TTE, in the absence of any apparent significant interval change in the 
enrollees clinical condition. Documentation would not point to a change in status that would support the 
medical necessity of a repeat TTE at this time. Our reviewer found that clinical guidelines do not support 
repeating a TTE following a previous TTE, with no intervening change in clinical status or new signs, 
symptoms or physical findings. Our physician reviewer also found that there is no supportive evidence for the 
medical necessity of repeat TTE in this enrollees clinical management. 
 
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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 a CGM and supplies. 
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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy sessions. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional therapy services are not an appropriate duration and 
frequency for treatment of the members medical condition and therefore are not 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy sessions.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy provided by a 
participating provider. 
 
You asked the Plan to pre-approve occupational therapy. You say that additional occupational therapy sessions 
are medically necessary. The Plan denied your request. The Plan says these services have been correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 occupational therapy. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional therapy services are not an appropriate 
duration and frequency for treatment of the members medical condition and therefore are not 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 occupational therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupational therapy provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diapers, disposable under pads, skin sealants, 
protectants, moisturizers, ointments, and gloves. 
 
You asked the Plan to pre-approve diapers, disposable under pads, skin sealants, protectants, moisturizers, 
ointments, and gloves. You say that the enrollee has advanced dementia and is bed bound. You say that the 
enrollee has no control over her bladder and bowel movements and is unable to request assistance with these 
bodily functions. You say that without the requested incontinence supplies the enrollee's hygiene will be 
drastically affected and her likelihood of developing infections will increase. The Plan denied your request. The 
Plan says the items being requested are not reusable and are used for hygiene. The Plan says that these items 
are non-covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve diapers, disposable under pads, 
skin sealants, protectants, moisturizers, ointments, and gloves.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on July 
28, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be paid. The Plan 
denied your request. The Plan says the service was 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 the nursing facility care. Our reviewer says 
that the requested nursing facility care was not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee has not had any symptoms of anxiety and claims they have no issues with the anxiety. The reviewer found that the enrollee had no concern 
about her mental health. The reviewer found that the enrollee did not require a visit with the physician for 
anxiety as they were not experiencing any symptoms. Therefore, the reviewer found that the service in this case 
was not 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 the nursing facility care have not been met. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care (99308) provided on July 28, 2022.