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

 
We decided that the Plan has to pre-approve an acute inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that your doctor recommended you go to 
the emergency room to get checked out. You say that upon arrival they thought you had a stroke. You also say 
that the services were medically necessary. The Plan denied your request. The Plan says that the inpatient 
admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 inpatient admission. Our reviewer 
says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician 
reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably 
expected that your necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
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 inpatient admission have been met. Therefore, we decided that the Plan has 
to pre-approve an acute inpatient hospital admission.  
 
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 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from May 
5, 2022. forward. 
 
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that inpatient 
psychiatric care continues to be medically necessary. The Plan denied your request. The Plan says the criteria 
for coverage are no longer met in this case. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continuation of inpatient psychiatric 
care. Our reviewer says that the requested inpatient psychiatric hospital care is not medically reasonable and 
necessary. Our physician reviewer found you are a 56-year-old male was admitted to the acute inpatient 
psychiatric hospitalization on April 27, 2022, with Major Depressive Disorder, Recurrent, Severe with 
Psychotic Features. Based upon review the records provided it was not expected this enrollee would improve in 
a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or 
others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats 
of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any 
suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. The Plans denial of 
continued inpatient psychiatric services appears 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 the continuation of inpatient psychiatric care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from May 5, 
2022. forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sterile gloves provided on December 11, 2021. 
 
You asked the Plan to pay for sterile gloves. You say that you are appealing with supporting records that 
indicate this was emergency care. The Plan denied your request. The Plan says the denial of payment for these 
supplies is correct, because code A4930 has a medically unlikely edit (MUE) value of 0 so is excluded from 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that a durable medical equipment, prosthetics, 
orthotics, and supplies (DMEPOS) item with a medically unlikely edit (MUE) value of 0 may be noncovered, 
not medically necessary, not separately payable, or invalid for claim submission.  
 
We looked at the file and Medicare rules. Code A4930 has a MUE value of 0, meaning that it has been 
determined to be not payable by Medicare. Based on this information, we decided that Medicare rules for 
coverage of sterile gloves have not been met. Therefore, we decided that the Plan does not have to pay for 
sterile gloves provided on December 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Orthovisc injection (J7324) provided on May 13, 2021. 
 
You asked the Plan to pay for Orthovisc. You say that the injection was medically necessary. The Plan denied 
your request. The Plan says that additional information is required. 
 
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 pay for Orthovisc. Our reviewer says that the 
Orthovisc injection was not medically necessary. Our physician reviewer found the provided documentation 
does not indicate any failure of conservative therapy, including medications and physical therapy. The reviewer 
found that the documentation did not support that the Orthovisc was medically reasonable and necessary for the 
enrollee. The documentation did not support that the Orthovisc was safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pay for the Orthovisc injection (J7324) provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on March 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip core decompression. 
 
You asked the Plan to pre-approve hip core decompression. You say that hip core decompression is a necessary 
procedure due to the diagnosis of avascular necrosis and the medical records justify the need for the procedure. 
The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes. 
 
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 hip core decompression. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that 
shows this request to be an effective and/or safe treatment for the noted pathology. The studies do not find this 
procedure as an effective treatment outside of the early stages. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hip core decompression have not been met. Therefore, we decided that the Plan 
does not have to pre-approve hip core decompression.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that this power 
wheelchair is medically reasonable and necessary. The Plan denied your request. The Plan says you do not 
meet the Medicare coverage criteria for the requested wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair and accessories.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from November 8, 2021, to 
November 12, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the services should be covered. The Plan denied 
your request. The Plan says that the services were 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 pay for the inpatient care. Our reviewer says that the 
inpatient care was considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation indicates that the inpatient care was 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 inpatient care have been met. Therefore, we decided that the Plan has to pay 
for the inpatient hospital care provided from November 8, 2021, to November 12, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health admission. 
 
You asked the Plan to pre-approve inpatient behavioral health admission. You say that the enrollee would not 
be safe in an unstructured, unsupervised setting such as individualized outpatient therapy only. You say that the 
enrollee continues to make minimal progress towards their safe interactions with others. You also say that the 
enrollee needs structure to prevent decompensation. The Plan denied your request. The Plan says the requested 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient behavioral health admission. 
Our reviewer says that the requested inpatient behavioral health admission is not medically necessary. Our 
physician reviewer found the records provided do not indicate that it was expected this enrollee would improve 
in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation, 
auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats 
to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as she did not have 
dangerousness to self or others and was compliant with her treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient behavioral health admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient behavioral health admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that the benefit limit according to 
Medicare rules has not been reached. The Plan denied your request. The Plan says two radiofrequency sessions 
have already been rendered for the 12-month rolling period. 
 
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two 
(2) radiofrequency sessions will be reimbursed per rolling 12 months 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that when this was 
requested the spinal regions in question had had 2 radiofrequency sessions within the last 12 months. Based on 
this information, we decided that Medicare rules for coverage of radiofrequency ablation services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has autoimmune hemolytic 
anemia. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved  drug compendia do contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation. Prednisone is therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prednisone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator (E0466). 
 
You asked the Plan to pre-approve a portable home ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode 
with or without Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable home ventilator have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a portable home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says the request exceeds the 
dose indicated by the accepted standard of practice. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
The file shows that 200 units per treatment of Botox was requested. 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 Botox. Our physician reviewer found that the record indicates the enrollee 
has a diagnosis of dysphagia in the setting of delayed gastric emptying following esophagectomy. The record 
indicates that the enrollee received an injection in 2021 of 100 units with good relief. The provided records do 
not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service at 
this time. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair replacement. 
 You asked the Plan to pre-approve the power wheelchair replacement. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the notes do not show that your current wheelchair is 
broken and cannot be fixed or that your condition has changed in a way that makes a new or different one 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair 
up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the 
beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power wheelchair replacement have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the power wheelchair replacement.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroplasty (23472) provided on November 8, 
2021. 
 
You asked the Plan to pay for the surgical service. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member 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 shoulder arthroplasty (23472) provided on November 8, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 10, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). The Plan denied your request. The Plan 
says procedure codes 00210 and 36620 have been overturned. The Plan also says CPT code 99100 remains 
denied as bundled services are not eligible for separate payment. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on November 10, 2021.