Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient services you received from 
October 3, 2022, to October 5, 2022. 
 
You asked the Plan to waive the coinsurance. You say that these are duplicate services. 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% 
coinsurance for Medicare-covered outpatient hospital services.  
 
Review of the file shows that you were provided outpatient hospital care from October 3, 2022, to October 5, 
2022. You have been asked to pay a 10% coinsurance, totaling $23.77, for the services. These services fall 
within the outpatient 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 coinsurance for 
the outpatient services you received from October 3, 2022, to October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee requires the use of a 
hospital bed to reduce pain, facilitate transfers and prevent pressure wounds not feasible in a regular bed due to 
stroke and hemiparesis. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of this type of hospital bed. 
 The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 semi-electric hospital bed. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found that hemiparesis does not 
require positioning not available with a standard bed and a hospital bed does not reduce risk of pressure sores.  
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
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 the enrollee cannot get the intensive rehab that they 
need in the acute hospital or a skilled nursing facility. The Plan denied your request. The Plan says while the 
enrollee will likely benefit from ongoing therapy to enhance their rehabilitation potential, there is no evidence 
that this cannot safely be done at a lower level of care. 
 
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 enrollee does not need an intensive therapy program. While the enrollee may 
benefit from physical and occupational therapy, their rehab needs can be provided in a lower intensity and 
alternate setting such a skilled nursing 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee hasn't completed the full 
course of treatment in the acute care setting. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation (A0429) provided on July 7, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that this is not a duplicate claim, as the 
enrollee was transported twice on the date in question. The Plan denied your request. The Plan says that this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, the Plan has not provided sufficient 
evidence to show that this is a duplicate of a previously paid claim. The two claims provided indicate different 
mileage amounts, which have both been paid, and the medical records provided support that the enrollee was 
transported twice on the date in question. Based on this information, we decided that Medicare rules for 
coverage of ambulance transportation have been met. Therefore, we decided that the Plan has to pay for 
ambulance transportation (A0429) provided on July 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81201, 81408, 81406, 81479, 81432, 81403 and 
81404) provided on June 15, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that this claim is denied. 
 
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 has not provided a clear reason for these services to be 
denied, nor has the Plan provided a relevant citation and supporting evidence to substantiate this denial. 
Therefore, we decided that the Plan has to pay for laboratory services (81201, 81408, 81406, 81479, 81432, 
81403 and 81404) provided on June 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment (DME) provided from September 23, 
2021, to September 24, 2021. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says that the required 
treatment records were not provided. 
 
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. The Plan argues that the required treatment records were not provided. However, 
the submitted documentation included a written order for the DME in question, as well as medical records 
supporting medical necessity. The documentation also contains and itemized delivery ticket for the items in 
question. The Plan has not provided documentation substantiating its denial. Therefore, we decided that the 
Plan has to pay for the durable medical equipment (DME) provided from September 23, 2021, to September 
24, 2021.  
 
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 Durolane injection. 
 
You asked the Plan to pre-approve Durolane. You say that the enrollee has been receiving injections every 6 
months for the past couple of years. You say that the enrollee is not a good surgical candidate. You also say 
that it is necessary for the enrollee to continue utilizing these injections to avoid intractable pain. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repeat injections for shoulder arthritis are limited to a 
single repeat course. 
 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 Durolane. Our reviewer says that the 
requested Durolane injection is not medically necessary. Our physician reviewer found the coverage criteria 
states that repeat injections of hyaluronic acid for shoulder arthritis are limited to a single repeat course. The 
reviewer found that the enrollee has had two prior injections already, so the single repeat course is completed. 
Therefore, the reviewer found that the Durolane injection 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH to help with 
getting off oxygen. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 
acute care and is currently unstable for transfer. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH, the enrollee is receiving appropriate care at the present acute care hospital. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional physical therapy visits 
 
You asked the Plan to pre-approve the therapy services. You say that continued therapy can help focus on 
reducing the enrollee's pain and increasing their mobility. The Plan denied your request. The Plan says 9 
additional physical therapy visits 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 the therapy services. 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 that the enrollee has an effective treatment program they are able to 
do as a home exercise program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 additional physical therapy visits
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minuteman procedure. 
 
You asked the Plan to pre-approve a minuteman procedure. 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 a minuteman procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for yours medical condition. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a minuteman procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of Oasis Burn bioengineered skin substitute 
(BSS). 
 
You asked the Plan to pre-approve the Oasis Burn BSS. You say that it is felt that this BSS product should be 
tried to help with wound healing. The Plan denied your request. The Plan says this product is considered 
investigational at this time. 
 
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 Oasis Burn BSS. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is a non-healing ulcer. He has a wound vac in place. The member is cognitively 
impaired and is minimally verbal. He was hospitalized from 12/01 to 12/07 for an infection to the right buttock pressure ulcer. On 12/05 he underwent debridement and Kerecis placement. There was an abscess and necrosis 
with no bone exposed. Stravix was used in the past for tissue growth optimization. The provider has 
recommended therapy with skin substitute graft (Oasis Burn Matrix). 
 
The requested BSS product is considered experimental. The member may qualify for a graft if an approved 
product is used. The review has determined that the items/services at issue in this case are 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 the Oasis Burn BSS have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of Oasis Burn bioengineered skin substitute (BSS).
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. The Plan denied your request. The Plan says the enrollee does not 
meet all the requirements, medically necessary care may be provided safely in a lower level of care. 
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that the requested physical therapy is 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that there is no 
documentation that skilled home health physical therapy services are required. The provided records do not 
document that the enrollee remains homebound. Progression to outpatient physical therapy treatment now 
appears to be appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five home health physical therapy visits.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve BRACAnalysis CDx (81162). 
 
You asked the Plan to pre-approve BRACAnalysis CDx. You say that the enrollee started chemotherapy on 
April 19, 2023, and this testing is medically necessary. The Plan denied your request. The Plan says that the 
criteria for coverage of this test are not met in this case. 
 
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 BRACAnalysis CDx. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that per the National Comprehensive Cancer Network (NCCN) guidelines, all 
patients with ovarian cancer, fallopian tube cancer or primary peritoneal cancer should have genetic risk 
evaluation and germline and somatic testing. Regardless of stage, this is a standard of care to guide both current 
and future decision making. This service is reasonable and 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 BRACAnalysis CDx have been met. Therefore, we decided that the Plan has to 
pre-approve BRACAnalysis CDx (81162).  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.