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 23, 2022, 
through July 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 these services. 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 with epigastric and right upper quadrant pain. He had underwent an 
esophagogastroduodenoscopy (EGD) for similar complaints recently which showed herpes esophagitis and 
signs of gastroparesis. He had been taking acyclovir but had nausea, vomiting (non-bloody) and pain. No more 
vomiting was reported that same day. The enrollee was COVID positive. He was dehydrated. He was treated 
with fluids, continued antiviral medications, and antibiotics. The enrollees vital signs were stable. Based on 
the low severity and low complexity of the presentation and emergency department (ED) workup, the enrollee 
was not expected to require hospitalization that would likely cross 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 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 23, 2022, through July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q9966 billed for date of service October 6, 
2022. 
 
You asked the Plan to pay for procedure code Q9966. You say that this service was reported appropriately. The 
Plan denied your request. The Plan says this code is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code Q9966 is low osmolar contrast material, 200-299 mg/ml 
iodine concentration, per ml. 
 
We asked our coder 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 procedure code Q9966. Our reviewer says that code Q9966 is not supported by the records provided. Our reviewer found the concentration of the contrast material is 
documented to be 180 mg/mL. There is a more accurate code to report the documented iodine concentration. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code Q9966 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code Q9966 billed for date of service October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown, porcelain fused to predominantly base metal 
(D2751). 
 
You asked the Plan to pre-approve a porcelain crown. You say that your health is being put in jeopardy by not 
being able to use your insurance plan to get a crown on your tooth. You have tried to get this tooth fixed since 
January and you cannot afford to pay for this crown on your own. The Plan denied your request. The Plan says 
the requested dental service is not covered by your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown, porcelain fused to predominantly base metal (D2751).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck 
provided on December 20, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound of the head and neck. You say that you would 
like the copayment to be reconsidered. 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 $100 
copayment for in-network basic radiological services performed at an outpatient hospital. 
 
You have been asked to pay a $100 copayment for an ultrasound of the head and neck. This item/service falls 
within the in-network basic radiological services performed at an outpatient hospital 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 ultrasound of the head and neck provided on December 
20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic injection provided on September 20, 2022. 
 
You asked the Plan to pay for a therapeutic injection. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a therapeutic injection 
provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 10, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on November 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the sleep study provided on January 29, 
2021. 
 
You asked the Plan to waive the coinsurance for the sleep study. You say that you were told there was a waiver 
for the coinsurance. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for the sleep study. This item/service 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. The total you owe is $65 ($325 allowed amount x 20% = $65). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the sleep study provided on 
January 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 26, 2022, to December 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $525 
copayment for inpatient hospital care. 
 
You have been asked to pay a $525 copayment for inpatient hospital care. This item/service 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 waive the copayment for inpatient 
hospital care provided on December 26, 2022, to December 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lutathera (A9513), every eight weeks for four cycles,
for retreatment for the enrollee.
You asked the Plan to pre-approve Lutathera. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that re-treatment is not recommended at this time.
Our Medical director looked at the case file and the reopen request. At issue is coverage for repeat dosing of
Lutathera. Our Medical Director states that there is insufficient support in the medical literature for repeat
dosing of Lutathera in the treatment of neuroendocrine tumor of the ileum with multiple metastases. Our
physician reviewer found that the enrollee's condition does not meet criteria for coverage of Lutathera.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Lutathera have not been met. Therefore, we decided that the Plan does not have
to pre-approve Lutathera (A9513), every eight weeks for four cycles, for retreatment for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a featherweight power scooter. 
 
You asked the Plan to pre-approve a featherweight power scooter. You say that you need the light scooter for 
daily activities like going to appointments, going to church, and more. The Plan denied your request. The Plan 
says you are requesting a power device that can be lifted into the car, which indicates that the need is for ease 
of transport outside the home, which is not covered by Medicare. The Plan also says your request does not meet 
Medicare criteria as medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a featherweight power scooter.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 was admitted for abdominal pain and gastrointestinal bleeding. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular aortic arch aneurysm repair using patient-
specific manufactured multi-branched stent graft with EEG monitoring, rapid ventricular pacing, and 
transesophageal echocardiogram (inpatient surgery). 
 
You asked the Plan to pre-approve vascular surgery. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is 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 vascular surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this technique is considered investigational at present given the absence of 
randomized, controlled trials to quantify clinical efficacy.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endovascular aortic arch aneurysm repair using patient-specific manufactured multi-
branched stent graft with EEG monitoring, rapid ventricular pacing, and transesophageal echocardiogram 
(inpatient surgery).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic imaging provided in an outpatient hospital 
setting on November 9, 2021, billed with code 77049. 
 
You asked the Plan to pay for the outpatient hospital imaging as billed. You say that this is medically necessary 
imaging that should be paid. The Plan denied your request. The Plan says breast sonography is not covered in 
this situation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 77049 has a status indicator of B in the Outpatient Prospective Payment System (OPPS). This means 
that the code is not recognized on outpatient hospital claims. Based on this information, we decided that 
Medicare rules for coverage of the outpatient hospital imaging as billed have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic imaging provided in an outpatient hospital setting 
on November 9, 2021, billed with code 77049.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjustable angle footplate. 
 
You asked the Plan to pay for an adjustable angle footplate. You say that the item should be covered. The Plan 
denied your request. The Plan says the claim is missing the right/left modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate left/right modifier. 
 
In this case, the CPT Code Manual definition of code K0040 is adjustable angle footplate.  
We find that CPT code K0040 is not supported in the medical record. Specifically, the code is missing the 
left/right modifier. Based on this information, we decided that Medicare rules for coverage of an adjustable 
angle footplate have not been met. Therefore, we decided that the Plan does not have to pay for an adjustable 
angle footplate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen E tank. You say that you want a portable oxygen tank to 
make it easier to leave the house. The Plan denied your request. The Plan says there is no indication the 
members current oxygen equipment is not meeting their medical needs or ADLs in or around the home. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a portable oxygen E tank. a portable oxygen E tank serves the same purpose as a 
portable oxygen E tank. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen 
concentrator (E1392).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. 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 he is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre therapeutic continuous glucose 
monitor (CGM) reader and sensors. 
 
You asked the Plan to pre-approve the FreeStyle Libre CGM and sensors. The Plan denied your request. The 
Plan says the enrollee does not require insulin three or more times daily. 
 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. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre CGM and sensors have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre therapeutic continuous glucose monitor (CGM) reader and sensors.