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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you just got out of the hospital from a total left hip 
replacement and have 2 arthritic knees and sciatica in your right leg. You feel the services are medically 
necessary. The Plan denied your request. The Plan says the records received do not indicate that you need an 
intensive therapy program with multiple visits from a rehab doctor per week. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CTA scan of the neck provided on June 14, 2022. 
 
You asked the Plan to pay for a CTA scan of the neck. You say that the services are correct and the provided is 
eligible for payment. The Plan denied your request. The Plan says the provider on this claim is on the exclusion 
list and are prohibited from submitting a claim. 
   
The Plan must follow Medicare rules. Medicare rules say that physicians, other practitioners, and suppliers who 
have been excluded from the Medicare program are prohibited from submitting claims or causing claims to be 
submitted.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CTA scan of the neck have not been met. Specifically, the referring provider on the claim is on the 
exclusion list which prohibits this claim from being paid. Therefore, we decided that the Plan does not have to 
pay for a CTA scan of the neck provided on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 16, 
2022. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says valid proof of delivery was not submitted. 
 
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 a valid proof of delivery for the specific item billed on this claim. The record 
shows that the Plan made attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on September 16, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for date of service November 3, 
2022. 
 
You asked the Plan to pay for the billed services. You say that it is impossible to continue treatment without the 
supplies. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file and the rules. The medical records show that the enrollee received supplies (code A4595) 
for a TENS unit for the treatment of low back pain. TENS is not reasonable and necessary for the treatment of 
CLBP. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code A4595 billed for date of 
service November 3, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Transcranial Magnetic Stimulation (TMS) (90867 x 
1, 90868 x 34 and 90869 x 1). 
 
You asked the Plan to pre-approve the TMS. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Left Prefrontal rTMS of the brain is considered 
medically necessary for use in an adult who meets all four of 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 the TMS. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the documentation presented does not specify 
what medications this patient had been taking during the present episode of depression. He had been tried on 
several pharmacologic agents from different categories including Prozac, amitriptyline, Zoloft, clomipramine, 
lithium and Xanax. The patient has undergone psychotherapy which he found to be less than efficacious. This 
patient did not show documentation of electroconvulsive treatment (ECT) or transcranial magnetic stimulation 
(TMS) in the past. The patient has no clear documentation of recent symptoms, or improvement with 
psychotherapy. 
 
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 TMS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Transcranial Magnetic Stimulation (TMS) (90867 x 1, 90868 x 34 and 90869 x 1).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that someone 
called an ambulance for you, and you said it should be cancelled. You also say that when the emergency 
medical technicians arrived, you let them take your blood pressure, but refused treatment. The Plan denied your 
request. The Plan says this claim denied correctly because you received non-transport ambulance services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aid (V5050) purchased on  
July 6, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not payable as it was 
purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from any network hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met. Specifically, the Plans contract states that hearing aids are covered 
when purchased from any network hearing aid provider. However, the hearing aid in this case was purchased 
from an out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for 
the hearing aid (V5050) purchased on July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lifeline bracelet alert device (A9280). 
 
You asked the Plan to pre-approve a Lifeline bracelet. You say that this is for your safety. You say that you feel 
this should be covered. You also say that your doctor wanted you to submit this request. The Plan denied your 
request. The Plan says this is an emergency communications system and does not serve a diagnostic or 
therapeutic purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Lifeline bracelet have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Lifeline bracelet alert device (A9280).
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the inpatient hospital stay provided from October 
27, 2022, to November 1, 2022. We decided that the Plan does not have to waive the copayment for the 
inpatient hospital stay provided from November 1, 2022, to November 11, 2022.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay provided by an in-network provider 
from October 27, 2022, to November 1, 2022, and November 1, 2022, to November 11, 2022. You say that you 
think that you were billed incorrectly. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for the inpatient hospital stay provided by an in-
network provider from October 27, 2022, to November 1, 2022.  
 
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 did not provide medical records or other documentation 
showing the billed services took place from October 27, 2022, to November 1, 2022, which you have disputed. 
 
We also decided that the Plan does not have to waive the copayment for the inpatient hospital stay 
provided by an in-network provider from November 1, 2022, to November 11, 2022. 
 
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 $325 
copayment per day, days 1-6, for each in-network Medicare-covered hospital admission. Therefore, we decided 
that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an in-network 
provider from November 1, 2022, to November 11, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 25, 2022, to 
February 1, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says the documentation 
does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code A41.50, described as 
gram-negative sepsis, unspecified. 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 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found although the enrollee had evidence of an infection, there was insufficient 
evidence to show a systemic infection that caused a dysregulated response leading to organ damage as required 
to justify the sepsis diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 25, 2022, to February 1, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 23, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were told that you would have 
no out-of-pocket cost. 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 $125 
copayment for Medicare-covered radiological diagnostic services, including ultrasounds, performed in a 
physicians office or at a free-standing facility. 
 
You have been asked to pay a $125 copayment for the ultrasound. This item/service falls 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 the ultrasound provided on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services provided on June 20, 
2022, and August 8, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you saw a dietician for obesity 
and digestive issues. You also say that you had to sign a waiver for these visits, but the rest of your visits were 
covered. The Plan denied your request. The Plan says the first decision to deny coverage for the medical 
nutritional services was correct. The Plan also says that the claim received from your provider did not have the 
diagnosis for either diabetes or renal (kidney) disease for this service to be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pay for the medical nutrition therapy services provided on June 20, 2022, and August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 3 Sensor. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 Sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an admission is 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 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee appeared to be stable enough to only require workup, electrolyte 
supplementation, fluids, and short-term monitoring which was not expected to require 2 or more midnights in the 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44021 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 44021. The Plan denied your request. The Plan says payment for 
code 44021 is bundled into payment for code 44960.  
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 44021 
is a column II code to column I code 44960. 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 44021 billed for date of 
service August 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's complicated 
medical history as well as their complex admission course, it is your strong recommendation that the enrollee 
be allowed admission to the LTACH level of care. The Plan denied your request. The Plan says the request for 
admission to an LTACH is denied as not medically necessary. 
 
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 appears to be stabilizing and should only require short-term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for a 
lower level of care. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to the LTACH would not be clinically advantageous and 
completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Forteo. 
 
You asked the Plan to pre-approve Forteo. You say that the requested drug is medically necessary for the 
ernollee's treatment. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Forteo.  
 Benefits for Forteo may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service April 13, 
2022. 
 
You asked the Plan to pay for procedure code(s) 88381. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88381. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88381. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service April 13, 
2022.