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

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that implantable loop recorders are only covered for 
certain 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 placement of a ILR. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an 
ILR in this enrollees clinical management. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional therapy (98702, 98703). 
 
You asked the Plan to pre-approve the nutritional therapy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve nutritional therapy (98702, 98703).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have myasthenia gravis which 
has responded to plasmapheresis. Two ABGs in hospital showed normal PaCO2, on the 3rd day it was 
increased for unclear reasons. You improved with bipap. There is no diagnosis of COPD, thoracic restrictive 
disease, or one of the neuromuscular diseases for which a ventilator is covered. BiPAP can provide the AVAPS 
mode of support. Medicare does not cover a home ventilator when used as bipap. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiography of bilateral extremities (75716) and 
additional angiography services (75774) provided on December 20, 2021. 
 
You asked the Plan to pay for an angiography of bilateral extremities and additional angiography services. You 
say that you have provided records to support the services billed. The Plan denied your request. The Plan says 
rules for payment have not been met because the services at issue are included in another billed code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 angiography of bilateral extremities and 
additional angiography services Our reviewer says that the services at issue do not meet criteria for payment. 
Our physician reviewer found that the operative report describes angiography with intervention. The described 
procedures would be included in CPT code 37227, as open or percutaneous endovascular revascularization 
includes all services performed to treat a single vessel.  
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 angiography of bilateral extremities and additional angiography services 
have not been met. Therefore, we decided that the Plan does not have to pay for an angiography of bilateral 
extremities (75716) and additional angiography services (75774) provided on December 20, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the intensity of an IRF. The Plan 
denied your request. The Plan says that the enrollee's needs can be met at an alternate level of care. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for osteomyelitis, knee effusion, and epistaxis. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on February 24, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you do not agree with the 
amount being charged. The Plan denied your request. The Plan says the cost-sharing amount you are being 
charged is correct. 
 
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 $150 
copayment for Medicare-covered outpatient hospital services. Covered services include but are not limited to: 
Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery. 
The provider billed in the amount of $181 and the Plan paid $48. Therefore, resulting in the total cost-sharing 
amount of $133, which is less than the copayment amount. 
 
 
 
 
 You have been asked to pay the allowed amount of $133, which is less than the copayment for outpatient 
services. Outpatient services fall within the Outpatient hospital services benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for outpatient services on February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient psychiatric services provided from April 28, 2021, to May 
29, 2021. 
 
You asked the Plan to pay for the inpatient psychiatric services. You say that due to the patient's continued 
suicidal behaviors and thoughts and the psychiatric provider's concerns about the safety of the patient, the 
Plan's denial must be overturned. The Plan denied your request. The Plan says that the enrollee did not meet the 
criteria for an inpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient psychiatric services. Our 
reviewer says that the admission of this patient does meet criteria for acute inpatient mental health treatment. 
Our physician reviewer found it was expected this patient would improve in a reasonable period of time as 
although she did not have dangerousness to self or others and was not showing any auditory/visual 
hallucinations, the patient was undergoing aggressive behaviors and active treatment. Our reviewer found that 
it did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level 
of care rather than a lower level of care. Active treatment was taking place and the services were reasonably 
expected to improve the patients condition. This patient was treated under an individualized treatment plan 
found in the record. It did appear that the records were supervised and evaluated by a physician. Our physician 
reviewer also found that the health plans denial of inpatient psychiatric services appears inappropriate. 
 
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 inpatient psychiatric services have been met. Therefore, we decided that the 
Plan has to pay for the inpatient psychiatric services provided from April 28, 2021, to May 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on April 12, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the anesthesia. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
anesthesia. We found no exception that would require the Plan to pay for the anesthesia. The records provided 
for review do not show that the anesthesia was urgent or emergent. Therefore, we decided that the Plan does not have to pay for anesthesia provided on April 12, 2021, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to reimburse you for the COVID-19 self-tests purchased on January 12, 2022. 
 
You asked the Plan to reimburse you for the COVID-19 self-tests. You say that you would like to be 
reimbursed for the COVID-19 home tests. The Plan denied your request. The Plan says that COVID-19 home 
tests require proof of physician order or involvement when purchased prior to January 15, 2022. 
 
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 has denied language citing contractual rules that require a 
physician order or involvement when a COVID-19 home test is purchased prior to January 15, 2022. However, 
the Plan did not provide proof of this rule anywhere in the case file. In addition, when attempting to find the 
policy on the Plans website, the language states that the Plan will reimburse members for the cost of Food and 
Drug Administration authorized self-tests purchased after January 1, 2022. The Plan has failed to provide 
evidence that supports their argument requiring proof of physician order or involvement when a COVID-19 
home test kit is purchased prior to January 15, 2022. Therefore, we decided that the Plan has to reimburse you 
for the COVID-19 self-tests purchased on January 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you 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 the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for lab services. You say that the doctor's office failed to send in a preauthorization 
form for approval. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 lab services provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from August 24, 2021, to 
August 27, 2021, as billed with diagnosis related group (DRG) 872. 
 
You asked the Plan to pay for inpatient care billed with DRG 872. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 690 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  
 
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 inpatient care billed with DRG 872. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found the enrollee with a past history of chronic 
obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes mellitus, obesity, chronic 
kidney disease (CKD) 3, chronic hypoxemic respiratory failure on 3L nasal canula, and hypertension, presented 
with sore throat and cough. The emergency department exam documented vital signs of temp 99.8, pulse 113, 
respiratory rate 18, blood pressure 132/58 and pulse oxygen saturation (SpO2) 94% on 2L nasal canula. The 
enrollee was described as alert and oriented x4, in no acute distress, lungs clear to auscultation, non-labored 
respirations, and no focal neurologic deficits. Laboratory test results included a white bloodcell count (WBC) 
of 19.7K, platelet count 213, blood urea nitrogen (BUN) 41, creatinine 1.8, total bilirubin 0.4, and lactic acid 
0.7. The enrollees chest x-ray was unremarkable, with a low volume view of chest. She was diagnosed with a 
urinary tract infection (UTI) and bronchitis and admitted for further care. Treatment included IV fluids and IV 
antibiotics. There was no laboratory or clinical evidence of sepsis. The review has determined that the medical 
records did not support the billing of sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 872 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from August 24, 2021, to August 27, 
2021, as billed with diagnosis related group (DRG) 872.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says epidural steroid injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that in 
this case there is no documentation of the degree of pain relief from the previous bilateral C6 and C7 TFESI on 
April 12, 2022. The review has determined that the requested ESI's do not meet the Medicare LCD coverage 
criteria. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for diagnostic services provided on January 31, 2022. 
 
You asked the Plan to waive the copayment for diagnostic services. You say that you already issued a payment. 
The Plan denied your request. The Plan says that you have been charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The Plan 
must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts 
to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit an Explanation of Benefits or claim form to support 
what services were billed and who provided the services on January 31, 2022. This means that we cannot 
determine the cost you are being asked to pay is correct or justified by the Plan contract. It is the burden of the 
Health Plan to substantiate their decision with evidence. In this case, the decision has not been substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to pay for the services billed on January 31, 
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.