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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 25, 2022, 
through July 28, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary. The Plan denied your request. The Plan says the acute inpatient hospital care provided 
was not medically necessary. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee presented to the emergency department (ED) with 
transient slurred speech and headache. In the ED the slurred speech was resolved but the headache persistent. 
She was diagnosed with dehydration. The computed tomographic angiography (CTA) scan provided showed a 
small area of ischemia. She was alert and in no distress with a grossly normal neurologic exam and stable 
vitals. Based on the low severity presentation with resolved neurologic symptoms, the continued workup could 
have safely been completed under an observation status. There was insufficient indication that the enrollee 
required hospital services that would have likely crossed 2 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from July 25, 2022, through July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components, and accessories, custom fabricated (L8702). 
 
You asked the Plan to pre-approve MyoPro 2 device. You say that the device is medically necessary and should 
be covered. The Plan denied your request. The Plan says the device is considered experimental, investigational 
and or unproven. 
 
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 MyoPro 2 device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a medical history of a stroke in 2015. A clinical progress note dated 
9/23/2022, indicated that the enrollee also has a medical history of hypertension, congestive heart failure, 
schizophrenia, depression, and migraine headaches. A MyoPro evaluation dated 5/26/2022, indicated that the 
enrollee had a stroke with resultant left upper extremity weakness. She was noted to have marked increase in 
muscle tone in the left upper limb. Motor strength was normal in the right upper extremity and 1-2/5 in the left 
upper extremity. The enrollee has attended occupational therapy and received Botox injections. The requested 
MyoPro myoelectric upper extremity orthosis was considered not medically necessary per guideline policy 
with the rationale that it is considered investigational and experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro 2 device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components, and accessories, custom 
fabricated (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve Trivisc. You say that the requested Trivisc injection is medically necessary. 
The Plan denied your request. The Plan says the requested Trivisc injection is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Trivisc. Our reviewer says that the 
requested Trivisc injection is not medically necessary. Our physician reviewer found the medical record does 
not document at least six (6) months have elapsed since the prior series of injections. The review has 
determined that the documentation does not support that Trivisc is medically reasonable or necessary for the 
enrollee.  The documentation does not support that Trivisc is safe and effective for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver (64590) and an implantable neurostimulator, pulse generator 
(L8679). 
 
You asked the Plan to pre-approve an eCoin device. You say that this procedure is medically necessary due to 
the enrollee's diagnosis of urge incontinence and her failure to adequately respond to multiple treatment 
options. The Plan denied your request. The Plan says while small trials have demonstrated efficacy of the 
device, more information is needed for long-term safety and efficacy data. Denied as not meeting Medicare 
basic rule requirements as it appears to be experimental and therefore is excluded. 
 
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 an eCoin device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of well controlled studies demonstrating long term safety and effectiveness of 
eCoin. Also, the records do not show that the enrollee has failed first and second-line treatments. 
 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 eCoin device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an insertion or replacement of peripheral or gastric neurostimulator pulse generator or 
receiver (64590) and an implantable neurostimulator, pulse generator (L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (tens) device 
provided on July 4, 2022. 
 
You asked the Plan to pay for a transcutaneous electrical nerve stimulation (tens) device. The Plan denied your 
request. The Plan says the documentation submitted did not indicate the provider discussed the need for the 
billed supply code; therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation submitted did not indicate the provider discussed the need for the billed supply 
code; therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a transcutaneous electrical nerve stimulation (tens) device provided on July 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 23, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
services are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered  . 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 services provided on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism chair (E0627). 
 
You asked the Plan to pre-approve a seat lift chair. You say that the requested item is medically necessary. The 
Plan denied your request. The Plan says you must meet criteria to be approved for a power seat lift chair. This 
chair is being denied because you would not be able to safely use the hand controls on the chair without help 
from others. A power seat lift chair can only be approved if you are able to safely use it. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are 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 a seat lift chair. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found you have weakness in your lower 
extremities, arthritis, blindness, and functional loss. You have symptomatic arthritis in your shoulders and 3/5 
strength in lower extremities. You require assists to walk and stand. The chair is not part of a therapeutic 
program. You do not have severe arthritis of hips or knees or an advanced neuromuscular condition. 
 
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 seat lift chair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism chair (E0627).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99308 billed for date of service April 26, 2022. 
 
You asked the Plan to pay for code 99308. You say that the place of service is nursing home and the fee is for a 
sequential nursing visit. The Plan denied your request. The Plan says you billed with an incorrect Place of 
Service (POS) on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that evaluation and management (E/M) services 
provided in a skilled nursing facility should be billed with POS code 31. In this case, you billed code 99308, 
which is defined as "subsequent nursing facility care, per day."  In addition, in your appeal request itself, you 
attested to the fact that the service in dispute occurred at a skilled nursing facility.  However, you billed with 
POS 21, which indicates that the service occurred in an inpatient hospital.  This is not correct.  The correct POS 
code that should have been billed is 31- Skilled Nursing Facility.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99308 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99308 billed for date of service April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cystourethroscopy with mechanical dilation and 
urethral therapeutic drug delivery. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says any drug, device, treatment or procedure that is experimental, investigational or 
unproven is not a covered benefit. 
 
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 the Optilume procedure is not medically reasonable and necessary in this case. Optilume is 
considered experimental and investigational. Although this device was Food and Drug Administration (FDA) 
approved in January of 2022, there are only two short term prospective studies that show that 2/3 of patients 
will not have a recurrent stricture requiring re-intervention at three years.  
 
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 a cystourethroscopy with mechanical dilation and urethral therapeutic drug delivery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection with unclassified drugs (J3490) billed for date of 
service December 1, 2021. 
 
You asked the Plan to pay for injection with unclassified drugs. You say that the service at issue has been billed 
correctly for payment. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules do not allow separate payment for an additional 
procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure 
and if billed without modifier -58, -78, or -79. 
 We looked at the file and Medicare rules. In this case, the service at issue has a global surgery fee period. The 
case record documents that the service at issue was furnished during the postoperative period of a prior 
procedure. The service at issue was not billed with the necessary modifiers. Based on this information, we 
decided that Medicare rules for coverage of injection with unclassified drugs have not been met. Therefore, we 
decided that the Plan does not have to pay for injection with unclassified drugs (J3490) billed for date of 
service December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit and laboratory services 
provided on June 7, 2022. 
 
You asked the Plan to waive the deductible for an office visit and laboratory services. You say that this should 
have been considered an annual wellness visit. 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. Your 
contract with the Plan says that there is a $250 deductible which applies to most covered services.  
 
The services you asked the Plan to waive the deductible for are not listed as exceptions to the deductible. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which 
applies to most covered services. This cost sharing is a contractual obligation that had not been met at the time 
an office visit and laboratory services was received on June 7, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for an office visit and laboratory services provided on June 7, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Paclitaxel and Gemcitabine. 
 
You asked the Plan to pre-approve Paclitaxel and Gemcitabine. You say that the requested Paclitaxel and 
Gemcitabine are medically necessary. The Plan denied your request. The Plan says that the requested Paclitaxel 
and Gemcitabine are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Paclitaxel and Gemcitabine. Our 
reviewer says that the requested Paclitaxel and Gemcitabine are medically necessary. Our physician reviewer 
found the requested use of Paclitaxel and Gemcitabine are FDA-approved for the enrollee's diagnosis. The 
enrollee has high clinical suspicion for pancreatic cancer based on imaging, symptoms, and elevated tumor 
marker with several failed attempts to obtain tissue. The enrollee understands clinical situation and wishes to 
try chemotherapy. The documentation supports that the requested Paclitaxel and Gemcitabine are safe and 
effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Paclitaxel and Gemcitabine have been met. Therefore, we decided that the Plan 
has to pre-approve Paclitaxel and Gemcitabine.  
 
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: Favorable

 
We decided that the Plan has to pre-approve an additional 22 one-way transportation trips. 
 
You asked the Plan to pre-approve an additional 22 one-way transportation trips. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says that they are unable to approve 
this request because their documentation indicates that you have already used up all your (24) one-way trips in 
this benefit year. 
 
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 failed to submit proof that the benefit has been exhausted. Without the 
proof, we cannot verify that the enrollee did indeed exhaust the benefit. Therefore, we decided that the Plan has 
to pre-approve an additional 22 one-way transportation trips.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the enrollee can safely 
receive care in another setting, such as Skilled Nursing Facility (SNF) or at home with home health services or 
outpatient setting if appropriate. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home infusion therapy provided from 
December 29, 2021, to February 8, 2022. 
 
You asked the Plan to waive the coinsurance for the home infusion therapy. You say that you would like the 
cost share to be reviewed to see if it can be reduced for the amount you would have to pay out-of-pocket. 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 a 20% 
coinsurance for in-network medical supplies.  
 
 
 
  
You have been asked to pay a 20% coinsurance for the home infusion therapy.  
 
DATE OF 
SERVICE 
ALLOWED 
AMOUNT 
 
PLAN PAID 
 
COINSURANCE 
December 29, 2021 $247.50 $198.00 $49.50 
January 1, 2022 $330.00 $264.00 $66.00 
January 5, 2022 $577.50 $462.00 $115.50 
January 12, 2022 $577.50 $462.00 $115.50 
January 19, 2022 $577.50 $462.00 $115.50 
January 26, 2022 $577.50 $462.00 $115.50 
February 8, 2022 $577.50 $462.00 $115.50 
 
These items/services fall within the home infusion therapy 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 coinsurance for home infusion therapy provided from December 29, 2021, to February 8, 2022.  
 
Your complaint about the poor provider customer service is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.