Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that the previous imaging shown you had a cyst, and a 
new MRI is medically necessary. The Plan denied your request. The Plan says the requested MRI is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
MRI of the brain is not medically necessary. Our physician reviewer found that the enrollee had an incidental 
finding of a pituitary cyst in May of 2022. The enrollee has deferred surgical evaluation at this time. The 
records provided for review did not otherwise indicate that the cyst was causing any issues for the individual. 
The enrollee has had no change in neurological or endocrine function noted since the time of the prior MRI. In 
such a setting, it cannot be said to be necessary to repeat imaging of a benign finding in such a short period of 
time. Nor would doing so be expected to result in any improvements in outcome/management. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the brain.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has trouble walking and needs 
assistance. The Plan denied your request. The Plan says that the enrollee has used all the skilled nursing facility 
days that are covered under their plan for the current benefit period. 
 
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 says the enrollee exhausted their 100-day SNF benefit. The 
records show there were more than 60 days between the discharge on July 8, 2022, and the admission on 
September 23, 2022. There is no evidence there was another inpatient stay in between those dates. This means 
that the Plan did not show the enrollee exhausted their 100-day benefit. Therefore, we decided that the Plan has 
to pre-approve SNF care.  
 
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 a Freestyle Libre continuous glucose monitor (CGM) 
reader. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee needs this diabetic supply. 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor (CGM) reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the evaluation was necessary to determine the 
plan of care. The Plan denied your request. The Plan says the payment for surgery includes same day visits. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99214 is included in the payment for minor procedure code 20610. The medical records 
do not show that the evaluation and management services were a significant, separately identifiable service.  
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 99214 billed for date of 
service August 2, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99217 provided on November 30, 2021. 
 
You asked the Plan to pay for procedure code 99217. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 99217 based on Medicare criteria. The Plan has failed to cite to any Medicare rule 
upon which its denial was based. The burden is on the Plan to supply enough information to support its denial. 
The Plan has failed to do so in this case. Therefore, we decided that the Plan has to pay for procedure code 
99217 provided on November 30, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jakafi. 
 
You asked the Plan to pre-approve Jakafi. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested medication does not fall under Part B coverage. The Plan says 
that they do not administer the enrollee's pharmacy benefits. 
 
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 Jakafi.  
 
Benefits for Jakafi 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: 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 services are necessary for the enrollee to receive 
the services needed before returning home. The Plan denied your request. The Plan says the services can be 
met at a lower level of care such as a skilled nursing facility or home health 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 there are no acute rehab nursing needs identified or documented. While the enrollee 
may benefit from physical and occupational therapy, the enrollee's rehab needs can be provided in a lower 
intensity and alternate setting such as in 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide. 
 
You asked the Plan to pre-approve the requested services. You say that you are entitled to home health aide 
services. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.   
We looked at the file and Medicare rules. We find that the services at issue in this case are considered custodial 
in nature. The documentation does not show that you are receiving qualified skilled services. Based on this 
information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a home health aide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and 
specialist office visit provided on September 28, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and specialist office visit. 
You say that you disagree with the cost share. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $45 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $45 copayment 
for specialist office visit. The total allowed amount for the prescription drugs $1,282.41. You are being asked 
to pay $256.48 ($1282.41 x 20% = $256.48). the total amount you are being asked to pay is $301.48 ($256.48 + $45 = $301.48). This item/service falls within the Medicare Part B prescription drugs and 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share 
for Medicare Part B prescription drugs and specialist office visit provided on September 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from February 8, 2022, to 
February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient admission. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not urgent or emergent, were foreseen and were 
obtained without authorization. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the inpatient admission provided from February 8, 
2022, to February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary for the enrollee to be able to 
return to their prior level of function. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare guidelines for IRF services. 
 
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 that the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left lower extremity revascularization. 
 
You asked the Plan to pre-approve left lower extremity revascularization. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lower extremity revascularization is only covered for 
certain indications. 
 
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 left lower extremity revascularization. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee has a non-healing ankle wound. The record indicates 
that the enrollee has normal ankle-brachial indices but diminished waveforms on arterial duplex examination. 
The records indicate that arteriogram is planned. The record does not indicate the presence of an atherosclerotic 
obstructive lesion. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left lower extremity revascularization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve left lower extremity revascularization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM) provided on November 7, 2022. 
 
You asked the Plan to pay for the supply allowance for CGM. You say that you are requesting reconsideration  
with supporting documentation to support the service requested. The Plan denied your request. The Plan says 
that the date of service billed on this claim does not match the shipping date or the date of delivery. 
 
The Plan follows Medicare rules. Medicare rules say that if a supplier utilizes a shipping service, the supplier 
may use the shipping date or the date of delivery as the date of service (DOS) on the claim. 
 
We looked at the file, and Medicare rules. The record shows that the shipping date of this item was November 
1, 2022, the delivery date was November 3, 2022, and the enrollee signed for the delivery on November 4, 
2022. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic continuous 
glucose monitor (CGM) provided on November 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's mileage limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need this 
transportation. The Plan denied your request. The Plan says the requested trips exceeds the Plan's mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the trip does not exceed 50 miles. 
 We looked at your request, the records in the case file, and the rules. The requested transport exceeds 50 miles 
of driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
miles for routine transportation beyond the Plan's mileage limit.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy (45385) provided on 
October 11, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that the service should be covered. 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 $150 
copayment for each Medicare- covered outpatient hospital service, including observation, outpatient surgery, or 
procedure.  
 
You have been asked to pay a $150 copayment for a colonoscopy. This item/service falls within the outpatient 
hospital services 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 colonoscopy 
(45385) provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740) and core buildup (D2950) provided on 
November 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the crowns (D2740) and core buildup (D2950) provided on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reclining lift chair (E1399). 
 
You asked the Plan to pre-approve a reclining lift chair. You say that you disagree with the denial and are 
requesting reconsideration for approval of the lift chair. The Plan denied your request. The Plan says the 
recliner lift chair does not appear to serve a primary medical purpose.  This item is not considered durable 
medical equipment and therefore is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a reclining lift chair (E1399).
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 you are unable to 
participate in or benefit from 15 hours of intensive therapy per week including two therapy types, medically 
necessary care may be provided safely in a different 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 there is not a reasonable expectation that the enrollee will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
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.