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

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 2 reader device 
 
You asked the Plan to pre-approve the Freestyle Libre 2. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
Freestyle Libre 2 reader device
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does require physical therapy and occupational therapy services, but the medical records provided do not 
clarify why the enrollee requires an intensive inpatient rehabilitation therapy program. The records do not 
explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower 
level of care such as in a skilled nursing facility is not appropriate for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 and F5 genetic testing services. 
 
You asked the Plan to pre-approve F2 and F5 genetic testing services. You say that these genetic testing 
services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing of F2 and F5 genes are only 
covered for pregnant patients. Based on this information, we decided that Medicare rules for coverage of F2 
and F5 genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-
approve F2 and F5 genetic testing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthotic Inserts (L3010). 
 
You asked the Plan to pre-approve foot orthotics. You say that the items are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve Orthotic Inserts (L3010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dex-Com Glucose Monitor and Sensors. 
 
You asked the Plan to pre-approve the Dex-Com Glucose Monitor and Sensors. You say that the item is 
medically necessary. The Plan denied your request. The Plan says you do not use insulin with at least three 
daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dex-Com Glucose Monitor and Sensors have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Dex-Com Glucose Monitor and Sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-speed motor and push handles. 
 
You asked the Plan to pre-approve the requested items. You say that the chair would be hard to push, and you 
could burn up the motor. The Plan denied your request. The Plan says the requested items are for convenience 
and comfort. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve a high-speed motor and 
push handles.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional unit of percutaneous access and closure of 
femoral artery (34713) provided on November 8, 2021.  You asked the Plan to pay for the additional unit of percutaneous access and closure of femoral artery (34713). 
You say that someone with a medical degree should review the attached operative report. The Plan denied your 
request. The Plan says the maximum units of service that a provider can report for this service is 1 and 2 units 
were 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 34713 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 the 
additional unit of percutaneous access and closure of femoral artery (34713) have not been met. Therefore, we 
decided that the Plan does not have to pay for the additional unit of percutaneous access and closure of femoral 
artery (34713) provided on November 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 1, 2021, to October 6, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $298 
copayment per day for days 1-7 of inpatient hospital care.  
 
 
  You have been asked to pay a $1,490 copayment for 5 days of inpatient hospital care ($298 x 5 = $1,490). 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 an inpatient hospital stay provided from October 1, 2021, to 
October 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from October 25, 
2021, to November 23, 2021. 
 
You asked the Plan to pay for the home health care services. The Plan denied your request. The Plan says the 
RAP claim was submitted on January 5, 2022, and was due within 5 days after the "from date" of October 25, 
2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, October 25, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health care services provided from October 25, 2021, to November 23, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cupholder (K0108) and electronic connection (E2310). 
 
You asked the Plan to pre-approve a cupholder and electronic connection. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the cupholder does not primarily serve a medical 
purpose and the electronic connection is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 an electronic connection. Our reviewer says that the 
member does not need this item. Our physician reviewer found that the member does have use of her hands and can operate and control the power options using the switches that are included in the basic wheelchair. 
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. The cupholder is 
available to the general public and would be helpful even to those who are not sick or injured. The electronic 
connection is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a 
cupholder (K0108) and electronic connection (E2310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Oral Nutritional Product. 
 
You asked the Plan to pre-approve the Oral Nutritional Product.. You say that the item is medically necessary. 
The Plan denied your request. The Plan says oral nutritional products are not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve the Oral Nutritional Product.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulator, low intensity ultrasound, non-
invasive (E0760). 
 
You asked the Plan to pre-approve osteogenesis stimulator. You say that this service is medically necessary to 
decrease the risk for nonunion. The enrollee is at very high risk for nonunion due to her malnutrition. The Plan 
denied your request. The Plan says the criteria for coverage of this service are not met, and therefore this 
service is 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 pre-approve osteogenesis stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has chronic anorexia with a fracture of the humerus and also has 
malnourishment and low body mass index. The enrollee underwent surgery on February 19, 2022. A request 
was made for an osteogenesis stimulator, low intensity ultrasound, non-invasive. However, the provided 
records did not clearly show x-ray results which show a non-healing fracture 90 days after the procedure to 
support this request. Therefore, the criteria have not been met for this service, and without evidence of a 
covered indication this request for the osteogenesis stimulator will be considered not medically necessary at 
this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteogenesis stimulator, low intensity ultrasound, non-invasive (E0760).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to adjust the coinsurance to the proper copayment for the radiation therapy. We 
decided that the Plan does not have to pay the copayment for the brachytherapy source. 
 You asked the Plan to pay the coinsurance for the radiation therapy. You say that you never received any 
durable medical equipment (DME) and should not be charged for it. The Plan says that the proper coinsurance 
was applied for the DME that was received at an in-network pharmacy or medical equipment provider. 
 
We decided that the Plan has to adjust the coinsurance for the proper copayment for the brachytherapy 
source.  
 
The Plan follows Medicare rules. Medicare rules say that the healthcare common procedure coding system 
(HCPCS) code of C2616 which is brachytherapy source, non-stranded, yttrium-90, per source falls under 
radiation therapy involving microscopic glass spheres containing the radioactive material yttrium-90. 
 
The file shows that you have a medical indication for which Medicare will cover the radiation therapy. 
Therefore, we decided that the Plan has to adjust the coinsurance for the proper copayment amount of $40 
dollars for the brachytherapy source.  
 
We also decided that the Plan does not have to pay the copayment for the brachytherapy source. 
 
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 $40 
copayment for the radiation therapy. Therefore, we decided that the Plan does not have to pay the copayment 
for the radiation therapy. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2330 x2) provided on 
December 21, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you expect these two fillings to be 
covered. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the 
frequency limitation has been exceeded. 
 
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, restorations are limited to two 
procedure codes per calendar year. The record shows that you received two resin-based composites (D2330 x2) 
on May 24, 2021 and your restorations benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the two resin-based composites (D2330 x2) provided on December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from May 17, 2021, to May 
21, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not 
supported as the principal diagnosis of sepsis, unspecified organism (A41.9) and secondary diagnosis of acute 
respiratory failure with hypoxia (J96.01) are not supported in the medical record. The Plan argues that DRG 
178 is more appropriate in this case.  
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. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the billing of principal diagnosis sepsis, unspecified organism (A41.9) and secondary 
diagnosis of acute respiratory failure with hypoxia (J96.01) is not supported in this case. Our physician 
reviewer found that the enrollee with dementia, chronic bronchiectasis, and chronic obstructive pulmonary 
disease (COPD) was admitted and treated in the hospital for shortness of breath. Vitals were stable. He was 
given fluids. Platelets, liver enzymes, kidney function were assessed and stable. The enrollee was on 3L of 
oxygen supplementation with normal pulse oximetry and weaned down to room air during course of treatment. 
Based on the provided documentation, the enrollee had pneumonia with aggravated COPD and bronchiectasis; 
the hypoxia was not significant enough to meet criteria for acute respiratory failure. Also, there was insufficient 
evidence from objective findings that the enrollee was experiencing organ failure from systemic changes 
related to the infection to meet Sepsis 3 criteria to justify the diagnosis of sepsis for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from May 17, 2021, to May 21, 2021, as 
billed with Diagnosis Related Group (DRG) 871.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device. 
 
You asked the Plan to pre-approve the MyoPro Motion G device. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested device is 
experimental/investigational. 
 
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 MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro Motion G device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on August 6, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory service provided on August 6, 2021.