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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2022, 
to June 5, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that this enrollee's inpatient admission 
was medically necessary. The Plan denied your request. The Plan says an inpatient admission was not 
warranted, as the inpatient criteria are not met. 
 
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 the 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 record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department 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 the acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2022, to June 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown represented by code D2740, and core 
buildup services represented by code D2950. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service May 9, 2019. On this date you 
received a crown and core buildup services for tooth 30, which is the same tooth you are requesting these 
services for now. Therefore, we decided that the Plan does not have to pre-approve a dental crown represented 
by code D2740, and core buildup services represented by code D2950.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the repairs. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover repairs when the expense for repairs exceeds the estimated 
expense for replacement of the wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs that are more expensive than replacing 
the durable medical equipment are not covered. 
 
The repair cost at this time would be $17,340.71, plus previous repairs that equal $1,991.08. The replacement 
cost for the same wheelchair is $9,519.29. Based on this information, we decided that Medicare rules for 
coverage of the repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve 
power wheelchair repairs.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Minuteman device to L4-L5 (CPT code(s) 22612 and 
22840). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Minuteman device in the setting of lumbar 
stenosis has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Minuteman device is experimental. More research is needed. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve Minuteman 
device to L4-L5 (CPT code(s) 22612 and 22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve cryoablation services. 
 
You asked the Plan to pre-approve the requested services. You say that cryoablation will provide longer relief. 
The Plan denied your request. The Plan says the services have not been demonstrated to improve clinical 
outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has chronic foot and ankle pain. She had a peripheral nerve stimulator of the 
superficial peroneal and tibial nerves placed but it was no longer effective. The request is for cryoablation of 
the affected nerves. The requested service is considered experimental/investigational. Therefore, the request is 
deemed 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nerve cryoablation services.
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 medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient does not require the intensity of rehabilitation physician oversight 
provided in the acute inpatient rehabilitation setting for complex medical issues. Her medical and rehabilitation 
needs do not require the intensive interdisciplinary approach provided in acute inpatient rehabilitation.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device placement for treatment of 
back pain (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the device is for treatment of back 
pain. Surgery is not covered, and injections do not work. The Plan denied your request. The Plan says the 
requested device is unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the vertiflex device is experimental. More research is needed as there is 
insufficient evidence of efficacy. 
 
 
 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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device placement for treatment of back pain (22869, 
22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits provided from 
March 19, 2022, to June 21, 2022, and a methylprednisolone injection provided on March 19, 2022. 
 
You asked the Plan to waive the cost share for the office visits and an injection. You say that you paid 
approximately $1,100 out-of-pocket and you would like your money refunded back to you. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for each specialist office visit. The Plan contract also says that enrollees must pay 20% coinsurance 
for Part B drugs. 
 
You have been asked to pay a $10 copayment for each specialist office visit received from March 19, 2022, to 
June 21, 2022. A specialist office visit falls within the physician/practitioner services benefit category. You 
have also been asked to pay $1.14, which is 20% coinsurance of the allowed amount for an injection received 
on March 19, 2022 ($5.70 allowed amount x 20% coinsurance = $1.14). An injection falls within the Medicare 
Part B drugs 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 the specialist office visits 
provided from March 19, 2022, to June 21, 2022, and a methylprednisolone injection provided on March 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic propulsion tire (CPT code E2211), insert for 
pneumatic propulsion tire (removable) (E2213) and foam caster tire (E2219). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says these items do not service a medical purpose. 
 
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 pneumatic propulsion tire (CPT code E2211), insert for 
pneumatic propulsion tire (removable) (E2213) and foam caster tire (E2219).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sandostatin LAR depot for arteriovenous malformation 
(J2353). 
 
You asked the Plan to pre-approve sandostatin LAR depot for arteriovenous malformation (J2353). You say 
that this patient has been on medication since April of 2020. The Plan denied your request. The Plan says the 
criteria for coverage is not met 
 
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 sandostatin LAR depot for 
arteriovenous malformation (J2353). Our reviewer says that the service is not medically necessary. Our 
physician reviewer found small bowel arteriovenous malformation bleeding is not cited by the Medicare-
approved major drug compendia as a medically accepted indication for use of sandostatin LAR depot. Our 
physician reviewer also found that there is no documentation that the sandostatin LAR depot at issue in this 
case meets all the Medicare criteria for safe and effective for the member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sandostatin LAR depot for arteriovenous malformation (J2353) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve sandostatin LAR depot for arteriovenous 
malformation (J2353).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an ILR is covered for the indications established in 
the applicable NCD. 
 
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 ILR. Our reviewer says that the 
requested ILR is not medically reasonable and necessary. Our physician reviewer found that while the enrollee 
has a history of atrial flutter, there is no documentation provided to suggest a history of unexplained syncope or 
any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this enrollee's clinical 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vertical shock 
reducing pylon feature (CPT code L5988). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the upgraded pylon is not reasonable and necessary for the approved leg prosthesis. 
 
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 item. Our physician reviewer found 
the office visit notes do not corroborate the vendor's notes showing need for L5988. The enrollee is K3 
ambulator, and K3 foot has already been approved. While the signed physician order includes L5988, per 
Medicare rules, "A prescription is not considered to be part of the medical record. Medical information 
intended to demonstrate compliance with coverage criteria may be included on the prescription but must be 
corroborated by information contained in the medical record. The review has determined that the medical 
records provided meet the requirements listed in the LCD for Medicare coverage. 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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve addition to lower 
limb prosthesis, vertical shock reducing pylon feature (CPT code L5988).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode, analysis and fluoroscopy (63650, 63685, 76000, 95972) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve an implantation of neurostimulator. You say that the in-network providers 
with the plan do not perform the appealed procedure. The requested provider is the only neurosurgeon to 
perform the procedure. The Plan denied your request. The Plan says there is an in-network provider that can 
provide the requested services. You must use network providers to get your medical care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a percutaneous implantation of neurostimulator electrode, analysis and fluoroscopy (63650, 63685, 76000, 
95972) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent 300/2ML injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Dupixent is a self-administered drug, and the medication does not fall under Part B 
coverage. 
 
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 Dupixent 300/2ML 
injection.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography and pulmonary diagnostic testing provided 
on April 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for echocardiography and pulmonary diagnostic testing. You say that your clinical 
documentation is clear and demonstrates medical necessity. You have submitted supporting documents and are 
requesting reconsideration of the denial. The Plan denied your request. The Plan says the enrollee must receive 
care from a network provider. 
 
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 echocardiography and pulmonary diagnostic 
testing provided on April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the requested treatment is 
considered safe and effective, as supported by its clinical benefits to patients, continued medical professional 
adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The 
Plan says the requested procedure is unproven and not medically necessary. The Plan says that there is 
insufficient evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our 
reviewer says that a Vertiflex Superion device is not considered medically reasonable and necessary in this 
case. Our physician reviewer found a Vertiflex Superion device is experimental, and more research is needed. 
 
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from January 31, 2022 to 
February 4, 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 
diagnosis of Acute respiratory failure with hypoxia is supported by the physicians' documentation and the 
information contained in the enrollee's medical record. The Plan denied your request. The Plan says diagnosis 
code J96.01 was removed from the claim, consistent with documentation received. 
 
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, J96.01, defined as Acute 
respiratory failure with hypoxia. 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 the submitted DRG is not supported. Our 
physician reviewer found there was no evidence to support acute respiratory failure with hypoxia. The review 
has determined that the medical records did not support the billing of Acute respiratory failure with hypoxia 
with DRG 175. Our reviewer also found that the revised DRG 176 is appropriate.  
 
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 from January 31, 2022 to February 4, 2022, at the Diagnosis Related 
Group (DRG) originally billed.