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

 
We decided that the Plan does not have to pay for the additional five dressing kits (A6550), provided on 
October 25, 2021, through October 26, 2021. 
 
You asked the Plan to pay for the additional five dressing kits. You say that the items are medically necessary. 
The Plan denied your request. The Plan says there was no documentation or information in the medical record 
provided that justifies the additional quantities greater than the limit that is allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is provided up to a maximum of 15 
dressing kits (A6550) per wound per month. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the additional five dressing kits have not been met. Specifically, the documentation submitted 
indicates you have already received the maximum allowed for this item. Therefore, we decided that the Plan 
does not have to pay for the additional five dressing kits (A6550), provided on October 25, 2021, through 
October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the injection of contrast for an x-ray study 
provided on August 17, 2021. You also asked the Plan to waive the copayment for the exchange of a biliary 
catheter provided on October 13, 2021. 
 
You asked the Plan to waive the copayments for the injection of contrast for an x-ray study and catheter 
exchange. You say that you were required to have the drain checked regularly after having surgery. You also 
say that these services were not done in an operating room. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 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 $250 
copayment for each outpatient surgery at an outpatient hospital.  
 
The record shows that the injection of contrast for an x-ray study and the exchange of a biliary catheter are 
considered surgical procedures. You have been asked to pay a total of $500, which is a $250 copayment for the 
injection of contrast for an x-ray study on August 17, 2021, and the catheter exchange on October 13,2021 
($250 copayment + $250 copayment = $500). The injection of contrast for an x-ray study and catheter 
exchange falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 copayments for the 
injection of contrast for an x-ray study provided on August 17, 2021, and the exchange of a biliary catheter 
provided on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health level of care. 
 
You asked the Plan to pre-approve inpatient behavioral care. You say that the requested inpatient level of care 
is medically necessary. The Plan denied your request. The Plan says the requested level of care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 inpatient behavioral care. Our reviewer 
says that the inpatient behavioral level of care is not medically necessary. Our physician reviewer found the 
provided records indicate it was not expected the enrollee would improve in a reasonable period of time beyond 
the dates in question as he was not showing any dangerousness to self or others, auditory or visual 
hallucinations and without aggressive behaviors while not showing any acute threats of safety. The reviewer 
found it did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any 
suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Therefore, the reviewer 
found that continued inpatient psychiatric services are 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 inpatient behavioral care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient behavioral health level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode that could 
be delivered by BiPAP is not covered. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that  Our physician reviewer found  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the enteral formula (B4152). 
 
You asked the Plan to pre-approve the enteral formula. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not covered when given by mouth instead of tube. 
 
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 enteral formula (B4152).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic complete glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for the 
enrollee's condition. 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 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
complete glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertical wheelchair lift. 
 
You asked the Plan to pre-approve vertical wheelchair lift. You say that this item is necessary for your 
condition. The Plan denied your request. The Plan says this item is not considered durable medical equipment 
and will not be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve vertical wheelchair lift.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to waive the copayment for ambulance services provided on December 16, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not live in 
Mississippi. You also say this is not your claim. The Plan denied your request. The Plan says that you have 
been charged the correct cost sharing amount. 
 
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. The Plan did not provide ambulance records to show if the services were 
provided to you. Without the ambulance records we are unable to determine if cost sharing applied correctly. 
Therefore, we decided that the Plan has to waive the copayment for ambulance services provided on December 
16, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is not covered due to insufficient 
evidence of efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the Intracept procedure have been met. 
In this case, no medical records have been presented to argue the medical necessity of the requested procedure. 
Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory continuous glucose monitor (95250, 95251), 
provided on March 3, 2021, to April 7, 2021. 
 
You asked the Plan to pay for the ambulatory continuous glucose monitor. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not have diabetes or on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that I-CGM devices will not be considered reasonable 
and necessary for the following: 
 
    Individuals that do not require insulin therapy. 
    Short-term I-CGM (72 hours to 1 week) for diagnostic use 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulatory continuous glucose monitor have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulatory continuous glucose monitor (95250, 95251), provided on March 3, 
2021, to April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service November 
11, 2021. 
 You asked the Plan to pay for procedure code 93976. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 93976 is bundled into payment for 
code 76857. 
 
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 93976 
is a column II code to column I code 76857. 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 93976 billed for date of service November 11, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for autologous blood or component, collection processing and 
storage (86891), special pump services (99190 and 99191) and washed red blood cells (P9022) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the autologous blood or component collection processing and storage, special 
pump services and washed red blood cells. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says payment for these services is included in the payment 
to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the autologous blood or component collection processing and storage, special pump services and 
washed red blood cells have not been met. Specifically, the records indicate that the enrollee was registered 
inpatient. Payment for these services is included in the payment to the facility and is the responsibility of the 
facility to any vendor. Therefore, we decided that the Plan does not have to pay for autologous blood or 
component, collection processing and storage (86891), special pump services (99190 and 99191) and washed 
red blood cells (P9022) provided on September 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latuda tablets. 
 
You asked the Plan to pre-approve Latuda tablets. The Plan denied your request. The Plan says Latuda is a self-
administered drug and 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 Latuda tablets.  
 
Benefits for Latuda tablets 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 waive the copayment for an endocrinology specialist telehealth visit 
provided on November 22, 2021. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that the visit was a three-
minute conversation not a real telehealth visit. You also say that it is inappropriate to charge a copayment on 
such an abbreviated, not in person, visit. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $15 
copayment for a specialist telehealth visit.  
 
 You have been asked to pay a $15 copayment for a specialist telehealth visit. A specialist telehealth visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an endocrinology specialist telehealth visit provided on November 
22, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G6 continuous glucose monitor (K0554) with sensor kit 
(K0553). 
 
You asked the Plan to pre-approve a Dexcom G6 monitor and sensors. You say that the requested items are a 
medical necessity for you. The Plan denied your request. The Plan says that rules for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not obtained and provided pertinent medical records 
from a provider in the Plan's network. It is the Plan's responsibility to substantiate its denial. Since the Plan has 
not substantiated its denial in this case, we must find in your favor. Therefore, we decided that the Plan has to 
pre-approve a Dexcom G6 continuous glucose monitor (K0554) with sensor kit (K0553).  
 
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 hearing aid (V5261), provided on November 21, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the cost share is wrong. The Plan denied your 
request. The Plan says the cost share was applied correctly. 
 
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. You are responsible 
for a 25% coinsurance and anything over $1,000 for hearing aids provided out-of-network.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Specifically, you are responsible for 25% coinsurance on 
purchases up to $1,000, and anything over $1,000 for out-of-network hearing aids. Your hearing aids cost 
$1,399; 25% of $1,000 is $250 and $1,399-$1,000= $399. This means you are responsible for $649. Therefore, 
we decided that the Plan does not have to pay for the hearing aid (V5261), provided on November 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sirolimus tablets. 
 
You asked the Plan to pre-approve Sirolimus tablets. You say that the enrollee requires immunosuppressant 
medications to prevent rejection of this transplanted heart. The Plan denied your request. The Plan says 
Sirolimus tablets are a self-administered drug and is not covered under the medical benefit. 
 
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 Sirolimus tablets.  
 
Benefits for Sirolimus tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from 
November 2, 2021, to November 6, 2021. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you feel a mistake has 
been made on the amount you are required to pay on this claim. You also say that you were expecting to pay a 
$320 copayment, the same amount that you have paid on previous operations. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $320 
copayment per day for days 1-5 of an inpatient hospital stay. The Plan contract also says that there is no charge 
after day 5. There is also no charge for the day of discharge. You have been asked to pay a total of $1,280, which is a $320 copayment per day for a four-day inpatient 
hospital stay ($320 copayment x 4 days = $1,280). There is no charge for the day of discharge. An inpatient 
hospital stay falls within the Inpatient Hospital Care 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 reduce the 
copayment for an inpatient hospital stay provided from November 2, 2021, to November 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a physical therapy visit provided on 
October 21, 2021. 
 
You asked the Plan to reduce the copayment for a physical therapy visit. You say that you should not be liable 
because you thought the copayment was $10. You also say that you had to quit physical therapy because you 
cannot afford it. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 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 $35 
copayment for an in-network physical therapy visit.  
 
You have been asked to pay a $35 copayment for a physical therapy visit. A physical therapy visit falls within 
the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for a 
physical therapy visit provided on October 21, 2021.