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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 Based on the documentation provided, the health plans denial should be upheld.  The enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not 
shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular 
physician evaluation.  The enrollees care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 pay for over-the-counter COVID-19 tests you purchased on January 
18, 2022. 
 
You asked the Plan to pay for the over-the-counter COVID-19 tests. You say that had you known these 
wouldn't be covered, you would have just gone to urgent care. The Plan denied your request. The Plan says 
coverage of at-home COVID-19 tests is only available after April 4, 2022, and only if purchased under 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that effective April 4, 2022, Original Medicare will 
cover up to eight over-the-counter COVID-19 tests each month.  For people in a Medicare Advantage (MA) 
plan, the tests covered under this initiative are covered outside of your existing plans coverage. You can get 
over-the-counter COVID-19 tests at any pharmacy or health care provider that participates in this initiative. 
Enrollees cannot submit a claim for these tests to Medicare or their MA plan for reimbursement under this 
initiative. The participating provider would bill Medicare directly for reimbursement of the tests provided to 
the enrollee.   
We looked at the file and Medicare rules. You did not purchase these tests after April 4, 2022, when the 
coverage rule took effect. In addition, even if you had, you did not follow the above-referenced procedure in 
order to have these covered.  Medicare Advantage Plans generally do not cover these tests.  Rather, they are 
covered by Original Medicare when you follow the instructions above. Based on this information, we decided 
that Medicare rules for coverage of the over-the-counter COVID-19 tests have not been met. Therefore, we 
decided that the Plan does not have to pay for over-the-counter COVID-19 tests you purchased on January 18, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 24, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 24, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 16, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity for the enrollee.  
 
Benefits for this drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat computed tomography (CT), heart, with 
contrast material, for evaluation of cardiac structure and morphology (75572). 
 
You asked the Plan to pre-approve a repeat cardiac CT scan. You say that the requested service is necessary to 
see if the aneurysm on the left artery has grown. You say that not having this scan scares you. You say that it 
has been over 3 months since the initial test. You also say that you are nervous about waiting until November 
for your next appointment. The Plan denied your request. The Plan says the requested CT scan of heart is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a repeat cardiac CT scan. Our reviewer 
says that the request for a repeat cardiac CT is not medically necessary. Our physician reviewer found the 
provided documentation from May 2022 indicates that repeat imaging was to be considered in six months. The 
reviewer found that the documentation does not support the rationale for repeating imaging studies at this time. 
Guidelines do not support a need for repeat imaging within this time frame given the enrollees clinical status. 
As a result, the reviewer found that at this time cardiac CT would not be considered medically appropriate and 
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 a repeat cardiac CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat computed tomography (CT), heart, with contrast material, for evaluation 
of cardiac structure and morphology (75572).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair wheel lock extensions. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says this is 
considered a convenience item for the caregiver. 
 
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. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve wheelchair wheel lock extensions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 7, 2021, to April 
9, 2021, as billed with Diagnosis Related Group (DRG) 330. 
 You asked the Plan to pay for inpatient care billed with DRG 330. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 330 is not 
appropriate as the diagnosis of acute posthemorrhagic anemia (D62) is not supported in the medical record. 
 
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 330. Our 
reviewer says that the diagnosis of acute posthemorrhagic anemia (D62) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found the enrollee was admitted and treated for 
diverticulitis without perforation, abscess, or bleeding. His hemoglobin level was 12 on April 9, 2021, and 
there is a report of the enrollee tolerating the procedure with no complication or other events following the 
procedure. There was no evidence provided of posthemorrhagic anemia. DRG 330 is not appropriate as the 
diagnosis of acute posthemorrhagic anemia (D62) is not supported in the medical record. 
 
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 330 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 7, 2021, to April 9, 2021, as 
billed with Diagnosis Related Group (DRG) 330.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of the 
requested item have not been met. 
 
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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro 
orthosis 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 the enrollee, 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 a MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM. 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 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 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre 2 continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services that are being requested do not meet the requirements for approval. 
 
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 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 (ex. SNF/SAR). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #2 provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve a crown. You say that these services are medically necessary. The Plan 
denied your request. The Plan says there is not enough tooth structure left. 
 
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 Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found criteria for D2740 for tooth #2 has 
not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #2 provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services 
you are requesting do not meet the requirements for approval. 
 
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 in this case, the complexity of the members nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The member does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the long compression stockings (A6533) provided 
on September 23, 2021, outside of the United States. 
 
You asked the Plan to reimburse you for the compression stockings. You say that you should be reimbursed for 
this. You say that you are on the other side of the world. You also say that they do not use procedure codes 
here. The Plan denied your request. The Plan says there is no coverage for non-emergency services that you 
receive outside of the United States. 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the compression stockings have not been met. Specifically, the file does not indicate that the long 
compression stockings were considered an urgent or emergent item. Therefore, we decided that the Plan does 
not have to reimburse you for the long compression stockings (A6533) provided on September 23, 2021, 
outside of the United States.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70554 billed for date of service March 12, 
2022. 
 
You asked the Plan to pay for procedure code 70554. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70554 is bundled into payment 
for code 70553.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70554 
is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70554 billed for date of service March 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ankle foot orthosis (L1971) and heel stabilizer (L3170) 
provided February 28, 2022. 
 
You asked the Plan to pay for the orthoses. You say that this claim met all of Medicare's DME LCD coverage 
criteria. The Plan denied your request. The Plan says the records do not support that the services were 
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 pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found The enrollee, with chronic back pain was listed as having osteoarthritis of the ankle and foot. 
The enrollee was examined and noted to ambulate without gait abnormality and had normal strength and tone 
of the legs, ankles, feet, without tenderness, bony abnormalities, misalignment, or abnormal range of motion. 
There was no imaging results or objective findings supportive of OA of the ankles or feet. Therefore, without 
clear objective abnormalities such as instability found on examination from recent documentation, there is 
insufficient support made for orthoses, and this request for such will be considered not medically 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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for Ankle foot orthosis (L1971) and heel stabilizer (L3170) provided February 28, 2022.