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

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from March 1, 2022, 
to March 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee came in by life flight and 
was not able to talk to the provider. The Plan denied your request. The Plan says that the admission does not 
meet the criteria for an inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record shows that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from March 1, 2022, to March 3, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has peripheral T-cell 
lymphoma and iron deficiency anemia and has failed oral iron replacement. He has not tried and failed the 
Plan's required drugs, Infed and Venofer. The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Feraheme is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided on January 4, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing provides actionable results for 
diagnosis and treatment. The Plan denied your request. The Plan says the testing is not covered. 
 
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 testing services. Our physician reviewer 
found that urine molecular tests, such as CxBladder for urothelial tumor markers are now available. Many of 
these tests have a better sensitivity for detecting bladder cancer than urinary cytology, but specificity is lower. 
Considering this, evaluation of urinary urothelial tumor markers may be considered during surveillance of 
high-risk non-muscle invasive bladder cancer (NMIBC). However, it remains unclear whether these tests offer 
additional useful information for detection and management of non-muscle invasive bladder tumors. Therefore, 
the service is not reasonable or 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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder test provided on January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from December 16, 
2021, to December 20, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was ordered based 
on the exercise of professional medical judgement, and in the best interest of the patient. The Plan denied your 
request. The Plan says that as of 12/16/21, the enrollee no longer met the criteria for inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee was admitted, started on IV antibiotics, and evaluated by infectious disease. 
The evaluation revealed a fluid collection in the gall bladder fossa. The review has determined that the record 
showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from December 16, 2021, to December 20, 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TMS (CPT code(s): 90867, 90869, 90868). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 services. Our physician reviewer 
found this enrollee does not have an indication for the requested TMS. This enrollee does not meet the LCD 
L34998 requirement for TMS. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TMS (CPT code(s): 90867, 90869, 90868).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74080 billed for date of service October 31, 
2021. 
 
You asked the Plan to pay for procedure code 74080. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74080 is bundled into payment for 
code 74050. 
 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 74080 
is a column II code to column I code 74050. 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 74080 billed for date of service October 31, 
2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from September 27, 
2021, to October 17, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the enrollee was stable and could have been safely care for at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that placement into skilled nursing facility (SNF) was sought for safe discharge planning, as the 
enrollee still required bilateral positive airway pressure (BiPAP) at night but was homeless with no place to go, 
and without anyone to help take care of him. The review indicates that the record showed that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from September 27, 2021, to October 17, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional test strips. 
 
You asked the Plan to pre-approve additional supplies. The Plan denied your request. The Plan says the 
available amount is adequate. 
 
The Plan must follow Medicare rules. Medicare rules say that a supplier must not dispense more than a three-
month quantity of testing supplies at a time.  
 
We looked at the file and Medicare rules. The file shows that a 100-day supply of tests strips were requested. 
The Plan has agreed to pre-approve a recurring 90-day supply. Test strips are covered every three months. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional test strips.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI), cervical spine (72141). 
 
You asked the Plan to pre-approve the MRI. You say that you need this service. The Plan denied your request. 
The Plan says that the requested MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is medically necessary. Our physician reviewer found the provided documentation indicates a 
reversal of normal lordosis and severe degenerative changes entire cervical spine. Therefore, the reviewer 
found the requested MRI to be medically reasonable 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 the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI), cervical spine (72141).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondadestron (J8597). 
 
You asked the Plan to pre-approve Ondadestron. You say that the enrollee is experiencing chronic nausea. You 
also say that the enrollee is intolerant to promethazine. The Plan denied your request. The Plan says coverage for the requested drug for the purpose of non-cancer, non-chemotherapy related, chronic nausea is not covered 
by Medicare 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 Ondadestron (J8597).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kit purchased on November 8, 
2021. 
 
You asked the Plan to pay for the at-home COVID-19 test kit. You say that the at-home COVID-19 test kit was 
necessary to allow you to travel. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kit is an OTC item. This item was purchased prior to Medicare advising health plans to provide 
coverage for at-home COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for the at-
home COVID-19 test kit purchased on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745-RR) provided on July 6, 
2021. 
 
You asked the Plan to pay for a neuromuscular stimulator. You say that this is supported in the records. The 
Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the 'RR' modifier is used when durable medical 
equipment (DME) is rented. 
 
We looked at the file and Medicare rules. The item at issue was billed with the RR modifier, but the 
submitted records indicate this item was purchased, not rented. Based on this information, we decided that 
Medicare rules for coverage of a neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pay for a neuromuscular stimulator (E0745-RR) provided on July 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a sleep study performed on April 14, 2022. 
 
You asked the Plan to reduce the copayment for the sleep study. You say that you were informed there would 
only be a $40 copayment. 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 $75 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
The file shows that the Plan reprocessed the claim to apply the correct copayment for diagnostic tests. 
Therefore, you have been asked to pay a $75 copayment for the sleep study. The sleep study falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 sleep study performed on April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided November 3, 2019, to January 3, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the itemized bill was not provided after multiple attempts to obtain. 
 
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 states that this appeal is denied due to the itemized bill was not 
provided after multiple attempts to obtain. However, review of the file shows an itemized bill with all of the 
different items billed during this inpatient stay. No other valid denial rationale was presented by the Plan. 
Therefore, the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
inpatient services provided November 3, 2019, to January 3, 2020.  
 
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 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 the services requested are 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 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 pre-approve a power scooter. You asked the Plan to pre-approve a power scooter. You say that your current scooter is broken. The Plan 
denied your request. The Plan says you have not had a face-to-face evaluation. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications. 
 
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 power scooter. Our physician 
reviewer found that you currently rely on a power scooter for mobility. However, there insufficient 
documentation from your physician regarding the status of your current scooter and the need for a new one. 
Additionally, the clinical progress notes indicate that a referral was made for a powered mobility evaluation, 
which is not provided for review. Without this information, the appropriate powered mobility device cannot be 
determined, if you can continue to safely operate a power scooter, or if your home is accessible for it. 
Therefore, the power scooter cannot be considered 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place.  
 
We looked at the file and Medicare rules. The services in this case were billed with an outpatient POS code. 
However, the records show that the enrollee was under inpatient status when the services were provided. This 
means that the services must be billed with an inpatient POS code. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services provided on March 21, 2022.