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

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need more trips. The Plan denied your 
request. The Plan says additional trips beyond the 24 allowed per year are not covered. 
 
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 a maximum of 24 one-way trips per year.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 24 additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs or documented skilled therapy needs. The enrollee is consistently ambulating 
more than 100. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, as a practical matter, can be provided 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided from October 25, 2021, to October 
28, 2021. 
 
You asked the Plan to pay for inpatient care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that the Medicare database shows that the enrollee's date of death is October 
2, 2021, which is before the date when these services were rendered. If the date of death is incorrect, the person 
in charge of the enrollee's estate would need to work with Medicare to get this information corrected. 
 
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, there is documentation provided in the record to indicate that the 
date of death listed by the Centers for Medicare and Medicaid Services is incorrect. An official copy of the 
death certificate from the state was included with the provided records, which lists the enrollees date of death 
as October 28, 2021. There are medical records provided to show that care was provided to this enrollee from 
October 25, 2021, to October 28, 2021. In addition, the provider is the appellant in this case, and the provider 
does not have the authority to request a correction with Medicare. The Plan has provided no other reason for a 
denial in this case. Therefore, we decided that the Plan has to pay for the inpatient hospital care provided from 
October 25, 2021, to October 28, 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: 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 you would like to appeal the denied services. The 
Plan denied your request. The Plan says the IRF services that are requesting from the long-term acute care 
hospital (LTACH) do not meet the requirements. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for patellar tendon rupture and knee infection. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee cannot read a glucometer. 
The Plan denied your request. The Plan says the criteria has not been met. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires 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 the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5299). 
 
You asked the Plan to pre-approve hearing aids. You say that the out-of-network provider is significantly less 
expensive. The Plan denied your request. The Plan says rules for coverage for hearing services have not been 
met. 
 
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 obtained through the Plan's hearing vendor. 
 
We looked at the file and the Plan's rules. In this case, the requested provider is not the Plan's hearing vendor. 
Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5299).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you feel that this decision is wrong. 
The Plan denied your request. The Plan says the criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 
 We reviewed the file and the Medicare rules. We find that you are 79 years old. This service is meant for 
enrollees between 55 and 77 years old.. Therefore, we decided that the Plan does not have to pre-approve a low 
dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection procedure for contrast knee arthrography or 
contrast enhanced CT/MRI knee arthrography (27369), knee x-ray (73580), dexamethasone sodium phosphate 
injection (J1100), betamethasone acetate and betamethasone sodium phosphate injection (J0702) and low 
osmolar contrast material (Q9967) provided on January 7, 2021. 
 
You asked the Plan to pay for the x-ray and injections. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the services billed. 
 
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, the CPT Code Manual definition of code 27369 is injection procedure for contrast knee 
arthrography or contrast enhanced CT/MRI knee arthrography.  
The CPT Code Manual definition of code 73580 is radiologic examination, knee, arthrography, radiological 
supervision and interpretation. 
 
The CPT Code Manual definition of code J1100 is injection, dexamethasone sodium phosphate, 1 mg. 
 
The CPT Code Manual definition of code J0702 is injection, betamethasone acetate 3 mg and betamethasone 
sodium phosphate 3 mg. 
 
The CPT Code Manual definition of code Q9967 is low osmolar contrast material, 300-399 mg/ml iodine 
concentration, per ml. 
 
We asked our coder 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 x-ray and injections. Our reviewer says that CPT codes 
27369, 73580, J1100, J0702 and Q9967 do not meet criteria for billing or reimbursement consideration. Our 
reviewer found the documentation does not support that these procedures were performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the x-ray and injections have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection procedure for contrast knee arthrography or contrast enhanced CT/MRI 
knee arthrography (27369), knee x-ray (73580), dexamethasone sodium phosphate injection (J1100), 
betamethasone acetate and betamethasone sodium phosphate injection (J0702) and low osmolar contrast 
material (Q9967) provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not 
been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as a power 
scooter. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power scooter 
(K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine one-way transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you do not have any family members or 
friends that live nearby with reliable wheelchair accessible transportation. You also say that you need 
transportation. The Plan denied your request. The Plan says extra one-way transportation trips cannot be 
approved. 
 
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 a maximum of 40 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The record shows 
that you have used 44 of the 40 allowed trips. Therefore, we decided that the Plan does not have to pre-approve 
additional routine one-way transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom continuous glucose monitor. 
 
You asked the Plan to pre-approve Dexcom continuous glucose monitor. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 and 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 Dexcom 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve Dexcom continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99204) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you are appealing the denial for neurology 
referral. The enrollee is already seeing this neurosurgeon. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 the outpatient office visit (99204) to be 
provided 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 you cannot move or stand, and you need to be 
admitted for inpatient rehabilitation level of care. The Plan denied your request. The Plan says the records do 
not show that the enrollee is able to take part in 3 hours of therapy 5 days per week, nor does the enrollee need 
an intensive team for care. The services the enrollee needs can be provided safely in other settings, for 
example, a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for weakness and a urinary tract infection. Medical problems are stable. There are no complex nursing 
or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria under the Center for Medicare and Medicaid Services (CMS) guidelines. The Plan denied 
your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's 
condition; she does not meet all of the requirements. 
 
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 there are no services at the LTACH that the patient requires that are not already 
available and covered at the current facility, and transfer to LTACH is not medically necessary as the patient is 
not yet stable and as it would not be clinically advantageous. Our physician also found that 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spa warm water treatment. 
 
You asked the Plan to pre-approve spa warm water treatment. You say that you have been battling joint pain, 
inflammation, and arthritis for years. The Plan denied your request. The Plan says the requested services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits.  
 
While the Plan does cover certain gym memberships, the requested spa treatment is not a covered benefit. 
Therefore, we decided that the Plan does not have to pre-approve spa warm water treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have congestive 
heart failure and recurring sepsis. You also say you have no car, no family, or friends to take you to your 
appointments or have the money to pay for transportation. The Plan denied your request. The Plan says The 
Plan says additional trips would exceed your benefit 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 a maximum of 20 trips per year.  
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
seventeen (17) one-way transportation trips out of the allowed twenty (20) one-way trips approved. Once 20 
trips are used, the benefit will be exhausted. 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 routine transportation trips (A0100).