Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wrist/ finger brace provided on January 
10, 2022. 
 
You asked the Plan to waive the coinsurance for wrist/ finger brace. You say that you never wanted the brace 
and didn't use it so it should be covered. The Plan denied your request. The Plan says the coinsurance applied is 
correct. 
 
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 20% 
coinsurance for braces.  
 
 
 You have been asked to pay $93.52 which is 20% of the allowed amount for wrist/ finger brace. The allowed 
amount is $467.58 (20% x $467.58= $93.52). Wrist/ finger brace falls within the Prosthetic Devices and 
Related Supplies benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for wrist/ finger brace 
provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block with fluoroscopy provided on 
November 22, 2021. 
 
You asked the Plan to pay for the genicular nerve block with fluoroscopy. You say that the genicular nerve 
block with fluoroscopy provided on November 22, 2021, was medically necessary. The Plan denied your 
request. The Plan says the genicular nerve block with fluoroscopy provided on November 22, 2021, 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 genicular nerve block with fluoroscopy. 
Our reviewer says that the genicular nerve block with fluoroscopy provided on November 22, 2021, was not 
medically necessary. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, 
including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a 
treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for 
individuals who are not candidates for knee replacement surgery. 
 
The review has determined that the genicular nerve blocks were 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 genicular nerve block with fluoroscopy have not been met. Therefore, we 
decided that the Plan does not have to pay for the genicular nerve block with fluoroscopy provided on 
November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strip. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus test strip. You say that these test strips are medically 
necessary. The Plan denied your request. The Plan says there is no specific rationale for the specific test strips 
over the Plan's preferred brand. 
 
The Plan follows Medicare rules. Medicare rules say that the non-preferred DME is subject to the criteria listed 
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 Accu-Chek Aviva Plus test strip. Our 
reviewer says that the requested test strips are not medically necessary. Our physician reviewer found that there 
is no documentation as to why a specific meter is needed for the enrollee. Therefore, the requested meter is not 
medically necessary per coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Accu-Chek Aviva Plus test strip have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Accu-Chek Aviva Plus test strip.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 8, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on March 
5, 2022. 
 
You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor 
(CGM) provided on March 5, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on February 6, 2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from 
August 10, 2020, through February 5, 2022. The Plan says, per Medicare guidelines, the provider must bill 
Original Medicare for the services provided on February 6, 2022. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care provided on February 6, 2022.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you are improving but still require acute care services before transitioning to a lower 
level of care. You continue to receive acute care services, and these have not been denied. The medical record 
does not indicate that you require services that you are not currently receiving but that would be available at the 
LTACH 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paravertebral facet joint injections (64494-XS, RT and 
64494-XS, LT) provided on February 22, 2022. 
 
You asked the Plan to pay for codes 64494-XS, RT and 64494-XS, LT. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of codes 
64494-XS, RT and 64494-XS, LT have not been met. Code 64494 has a bilateral surgery indicator of 1 and 
must be reported with 1 unit of service and modifier 50 (bilateral modifier). Therefore, we decided that the Plan 
does not have to pay for the paravertebral facet joint injections (64494-XS, RT and 64494-XS, LT) provided on 
February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 12, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 12, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that IRF care is not medically necessary and the enrollee's needs can be met at a 
lower level of care such as in a skilled nursing facility, at home with home health services or at home with 
outpatient therapy. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that IRF criteria has been met and the enrollee would benefit from close medical monitoring on an 
inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
29, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that the lab work was ordered by your 
doctor the same day as your annual physical. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 
copayment per day for lab tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for the lab services. Please note that these services are not 
included in the annual physical benefit. The lab services fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
laboratory services provided on November 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block (MBB) injections. 
 
You asked the Plan to pre-approve the requested MBBs. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested injection services do not satisfy coverage 
criteria. 
 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint injections are indicated when there is 
absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint 
synovial cyst). 
 
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 for the requested MBBs. Our reviewer says that the 
requested MBBs are not medically reasonable and necessary. Our physician reviewer found the enrollee is a 
57-year-old male with low back pain due to lumbar spinal stenosis with radiculopathy. According to the 
coverage criteria, facet joint injections are indicated when there is absence of untreated radiculopathy or 
neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst).  In this case, the enrollee 
has lumbar radiculopathy. The review has determined that the enrollee does not satisfy the LCD coverage 
criteria for the requested MBBs. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the requested MBBs have not been met. Therefore, we decided that the Plan does not have to pre-
approve medial branch block (MBB) injections.
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 the requested CGM is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the 
enrollee does not meet criteria for the requested CGM. Our physician reviewer found the record indicates that 
the enrollee has diabetes.  The record indicates that the enrollee regulates her insulin by the type of food she 
eats, not the blood sugar readings. The elements of the coverage criteria are not satisfied.  The requested service is not recommended. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a permanent cardiac contractility 
modulation system. 
 You asked the Plan to pre-approve the insertion of a permanent cardiac contractility modulation system. You 
say that failure of conservative treatment including mediation as well as key clinical findings, specifically left 
ventricular ejection fraction (LVEF) of 40-60% support recommendation for participation in the AIM HIGHer 
clinical trial for the Optimizer Smart Mini System. You say that health plan as required to cover routine patient 
costs incurred by qualified individuals who are participating in an approved clinical trial. You say that the 
enrollee meets the criteria for coverage of the requested clinical trial, including coverage of all associated 
routine care items and services. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the insertion of a permanent cardiac contractility modulation 
system as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of a permanent cardiac 
contractility modulation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three wheelchair and accessories. 
 
You asked the Plan to pre-approve a group three wheelchair and accessories. 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 items. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
Review of the file shows that most of the documentation provided to the Plan is not legible. The enrollee's 
home evaluation was in the enrollee's current facility and not in the enrollee's home. There is no information to 
show that the enrollee can use the equipment safely or will be able to be used inside the enrollee's home. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group three wheelchair and accessories.
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 services required exceed the clinical 
capabilities of lower levels of care. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require 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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with septic shock in the setting of 
peritonitis from intestinal perforation and decompensated cirrhosis. The enrollee still requires acute care 
services, including pressor support for hypotension. The enrollee continues to receive acute care services and 
these have not been denied. The medical record does not indicate that the enrollee requires services that she is 
not currently receiving but that would be available at the LTACH 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract surgery performed on November 
29, 2021. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that you are on a limited income 
and cannot afford the copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $270 
copayment for surgical services at an outpatient hospital.  
 
You have been asked to pay a $270 copayment for the cataract surgery. The cataract surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 copayment for a cataract surgery 
performed on November 29, 2021.