Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for outpatient hospital observation provided 
February 25, 2022, to February 27, 2022. 
 
You asked the Plan to reduce the coinsurance for outpatient hospital observation. You say that you believe the 
services should be coded as inpatient. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 20% 
coinsurance for each in-network observation room service you get at an outpatient hospital.  
 
 
 
 You have been asked to pay $2, 480.42 for outpatient hospital observation. The record shows your knee 
replacement surgery was performed as an outpatient procedure. This item/service falls within the outpatient 
hospital observation 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 coinsurance for outpatient hospital 
observation provided February 25, 2022, to February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and one year of 
supplies (K0553, K0554, E1399). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you disagree with the denial because you 
are worried about your sugar dropping too low. You need the requested CGM and supplies. The Plan denied 
your request. The Plan says you do not meet coverage criteria of approval of a CGM and related supplies. 
 
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 CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and one year of supplies (K0553, K0554, E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary visit and podiatry services provided on May 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary visit and podiatry services. You say that the services were 
medically necessary, and you are appealing with supporting records. The Plan denied your request. The Plan 
says the enrollee must receive care from a network provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary visit and podiatry services provided 
on May 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the trial is the last option the enrollee 
has for pain relief. The Plan denied your request. The Plan says the enrollee has not had maximum medical 
management. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulation is 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 the requested services. Our physician 
reviewer found that the enrollee is status post spine surgery. She has significant pain post-operatively. She was 
unable to tolerate physical therapy. She has started several pain medications but there is no documentation of 
maximum dosages or significant side effects. The request is for a spinal cord stimulation trial. The enrollee has 
not tried chiropractic, acupuncture, massage, or a transcutaneous electrical nerve stimulation (TENS) unit. The 
psychiatric evaluation showed significant depression, rumination, and magnification of symptoms. She has not 
had maximum medical management. The request is deemed not medically reasonable or necessary at this point. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the denial of payment is incorrect. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that the enrollee was an inpatient at the time the services were provided. We looked at the file 
and the rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for 
services furnished to a beneficiary. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers. This service was provided via arrangement 
of the facility.  Payment for this service would have been included under the facility claim. Payment to you for this service is 
the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on June 2, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on April 14, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says that this testing was not medically 
necessary since the documentation does not support recurrent, relapsed, refractor, or advanced lung cancer. 
 
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. In this case, the Plan originally denied coverage for the rendered services stating 
that preauthorization was not obtained for the services rendered. The claim has now denied as being not 
medically necessary. There is no indication that the Plan made a reasonable and diligent effort to obtain 
medical records from the provider that would support the medical necessity of the services in question. 
Therefore, we decided that the Plan has to pay for the genetic testing services provided on April 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve liposuction and scar revision for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the extra tissue is not causing any infections, pain, problems with ability to activities of 
daily living. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has a thigh scar and redundant skin. The record 
does not document the presence of one of the enumerated conditions for which coverage is available. The 
record does not indicate the presence of functional impairment.  The elements of the coverage criteria are not 
satisfied. 
 
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 liposuction and scar revision for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9500 and S9501 billed for date of service 
March 17, 2022, to March 23, 2022. 
 
You asked the Plan to pay for procedure codes S9500 and S9501. You say that the codes are valid. The Plan 
denied your request. The Plan says the billed codes are invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes S9501 and S9500 have a Status Indicator of I on the Physician Fee Schedule. 
This means that the procedure codes are not valid for Medicare purposes. 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 pay for procedure codes S9500 and S9501 billed for date of service March 17, 2022, to March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88291) provided March 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says medical records were not submitted for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 lab services have been met. In this 
case the claim was denied based on medical necessity. The Plan needed additional information to review the 
case. The Plan sent multiple requests for associated progress/consultation notes that provide the clinical 
indications for this testing. This information was not provided. Thus, we cannot determine how the enrollee 
came to the servicing provider, or whether the services are medically necessary. Therefore, we decided that the 
Plan does not have to pay for the lab services (88291) provided March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wrist hand orthosis, wrist extension control cock-up, 
non-molded, prefabricated brace (L3908) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a wrist hand orthosis. You say that you broke your wrist, and this brace was 
recommended to you. The Plan denied your request. The Plan says you must receive your care from a network 
provider. The Plan also says there are in-network providers available. 
 
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 a wrist hand orthosis, wrist extension control 
cock-up, non-molded, prefabricated brace (L3908) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on April 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the services were provided in good faith The 
Plan denied your request. The Plan says utilization of network providers and authorization for certain services 
are required. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. The record does not include documentation of a consultation or an attempt to consult the enrollee's 
primary/attending physician as required by Medicare rules. We found no exception that would require the Plan 
to pay for these services. Therefore, we decided that the Plan does not have to pay for the mental health 
services provided on April 5, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA disc procedure. 
 
You asked the Plan to pre-approve the VIA disc procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VIA disc procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 75-year-old female being treated for lumbar degenerative disc 
disease. She presented with low back pain. The pain is constant, sharp, and wakes her up.  
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this requested 
procedure to be an effective and/or safe treatment for the noted pathology.  
 
 Further studies are needed to demonstrate this request has beneficial outcomes compared with conventional 
treatment. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested VIA disc procedure, in this case, is 
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 the VIA disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VIA disc procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional 10 physical therapy (PT) visits (97164). 
 
You asked the Plan to pay for an additional 10 PT visits. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 an additional 10 PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested services are not medically necessary. While the 
documentation indicates that the enrollee has had an increase in falls, there is a lack of documentation 
indicating a significant change in baseline measures and if the enrollee is making continued progress with 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 10 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pay for an additional 10 physical therapy (PT) visits (97164).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82570 and 83986 billed for date of service 
March 23, 2022. 
 
You asked the Plan to pay for procedure codes 82570 and 83986. The Plan denied your request. The Plan says 
payment for codes 82570 and 83986 is bundled into payment for code 80307. 
 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 codes 
82570 and 83986 are column II codes to column I code 80307. 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 codes 82570 
and 83986 billed for date of service March 23, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 the enrollee appears to be improving but is somewhat unstable and requires 
additional short term acute care services that can be safely administered at the current facility until more stable 
and appropriate for 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 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: 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 member does not appear to meet 
Medicare criteria for an IRF admission. 
 
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 an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different 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 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.