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

 
We decided that the Plan does not have to pre-approve continuation of an inpatient psychiatric hospital 
admission after March 22, 2022. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee is not yet 
stable and is not safe to be discharged back to the community. The Plan denied your request. The Plan says as 
of March 23, 2022, it is not medically necessary for the enrollee to be treated in an inpatient mental health 
setting. The enrollee can continue treatment in a less restrictive setting, such as with outpatient services. 
 
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 pre-approve continued inpatient psychiatric care. 
Our reviewer says that the health Plan's denial of continued psychiatric care at the inpatient level is appropriate 
in this case. Our physician reviewer found that the enrollee was involuntarily admitted to the acute inpatient 
psychiatric hospitalization on March 2, 2022, with Unspecified Psychosis and Delusional Disorder. Based upon 
review the records provided it was not expected this enrollee would improve in a reasonable period of time for 
the dates in question as she did not have suicidal or homicidal ideation or auditory or visual hallucinations. It 
did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level 
of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self 
or others and was compliant with her treatment. It did not appear that active treatment was taking place beyond 
the date in question. It did not appear that the services were reasonably expected to improve the enrollees 
condition or for the purpose of diagnosis beyond the date in question. Based upon a review of the provided 
records, the admission of this enrollee does not meet the criteria for March 23, 2022, forward.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continuation of an inpatient psychiatric hospital admission after 
March 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the additional physical therapy sessions are 
medically necessary. The Plan denied your request. The Plan says medical records were requested and never 
received. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode chair with wheels (E1399). 
 
You asked the Plan to pre-approve a commode chair with wheels. You say that the item is medically necessary. 
The Plan denied your request. The Plan says a commode chair with wheels is not medically necessary and the 
member already has a standard commode chair. 
 
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 standard commode chair. a standard commode chair serves the same purpose as 
a commode chair with wheels. Therefore, we decided that the Plan does not have to pre-approve a commode 
chair with wheels (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240), implant supported crowns (D6066) 
and prefabricated abutments (D6056) for teeth #19-#21. 
 
You asked the Plan to pre-approve the dental services. You say that you want the crown portion of this request 
covered. The Plan denied your request. The Plan says these services are not covered by your dental benefit. 
 
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. The Plan does not cover 
services that are not listed in the dental benefits section of the contract. The Plan does not cover services 
associated with dental implants. 
 
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 and/or are associated with dental implants. Therefore, we decided that 
the Plan does not have to pre-approve a pontic (D6240), implant supported crowns (D6066) and prefabricated 
abutments (D6056) for teeth #19-#21.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that you feel that the enrollee 
needs the Freestyle Libre so he can monitor and really know what is going on with his blood glucose and how 
it responds to foods. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare 
criteria at this time. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre CGM and supplies. 
Our reviewer says that the requested items/services is considered medically reasonable and necessary in this 
case. Our physician reviewer found although the enrollee is not taking 3 shots per day that are adjusted based 
on his blood glucose, it seems as if the doctor feels that the enrollee is unable to use the glucometer correctly 
and hence the CGM would be medically necessary for this 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 a Freestyle Libre CGM and supplies have been met. Therefore, we decided that 
the Plan has to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.  
 
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 the chemotherapy administration, intravenous infusion 
technique coded as 96413 provided on November 1, 2021. 
 
You asked the Plan to pay for the chemotherapy administration, intravenous infusion technique. You say that 
you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The 
Plan says there is a more appropriate CPT code for the services rendered. 
 
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 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
We find that CPT code 96413 is not supported in the medical record. Specifically, this code is indicated for 
chemotherapy administration. However, the drug that was administered, Orencia, is not chemotherapy. Based 
on this information, we decided that Medicare rules for coverage of the chemotherapy administration, intravenous infusion technique have not been met. Therefore, we decided that the Plan does not have to pay for 
the chemotherapy administration, intravenous infusion technique coded as 96413 provided on November 1, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the requested item performs the same function as 
equipment that you currently use for your oxygen needs within the home. There is no physician order and no 
evidence that the items will satisfy your needs within 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 stationary oxygen concentrator, M6 tank and backup E tanks. These items serve 
the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-
approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home-delivered meals post-discharge for the enrollee. 
 
You asked the Plan to pre-approve the meals. You say that this is medically necessary. The Plan denied your 
request. The Plan says congestive heart failure must be the primary diagnosis. 
 
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 meals. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found while the patient had left ventricular dysfunction, with reduced ejection fraction, among his multiple co-
morbidities, congestive heart failure did not play a significant role is this hospitalization. As such, the 
documentation does not support authorization for home-delivered meals post discharge. 
 
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 meals have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home-delivered meals post-discharge for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 5, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
you should not have been billed for this service. The Plan denied your request. The Plan says you declined 
transport to the hospital, and no ambulance transport was provided. The Plan also says that ambulance response 
and treatment with no transport is not a payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 5, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on October 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with lesion 
removal provided on February 4, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this procedure was a 
screening colonoscopy. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 
copayment for outpatient surgery at an outpatient hospital.  
 
The medical record shows that lesions were removed during your colonoscopy on February 4, 2022. Therefore, 
this procedure is considered a diagnostic colonoscopy, and a cost sharing applies. You have been asked to pay 
a $400 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a diagnostic colonoscopy with lesion removal 
provided on February 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on November 1, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the service was rendered in good faith, and you believe it should be reprocessed for payment. The Plan denied 
your request. The Plan says the service rendered requires authorization and there is not one on file. 
 
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 non-emergency ambulance 
transportation (A0428) and ground mileage (A0425) provided on November 1, 2021. have been met. 
Specifically, the non-contracted provider did not provide medical records for this case. Therefore, we decided 
that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and ground 
mileage (A0425) provided on November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) provided on 
December 22, 2021. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that you picked up a rental van to 
transport the enrollee to another facility which you paid for out of pocket. The Plan denied your request. The 
Plan says a prior authorization or primary care physician referral is required for this service. The Plan also says 
that this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Having family rent a 
chair van to drive the enrollee across multiple states, not to the nearest facility, and not using a licensed 
provider, is not covered. Therefore, we decided that the Plan does not have to pay for the wheelchair van 
transportation (A0130) provided on December 22, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not supported because the enrollee has not tried other treatments. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract does not indicate that it has implemented such criteria for 
certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vabysmo. Our reviewer says that the 
requested use of Vabysmo is supported. Our physician reviewer found exudative age-related macular 
degeneration is an FDA-labeled indication for Vabysmo. Vabysmo is medically reasonable and necessary for 
the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have been met. Therefore, we decided that the Plan has to pre-
approve Vabysmo.  
 
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 the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the CardioMEMS device at this point should only be approved for patients enrolled in a 
clinical trial. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the lab tests are included in the dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor provided on May 23, 2021. 
 
You asked the Plan to pay for the provided device. The Plan denied your request. The Plan says the 
documentation did not support the billed supply code. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the physician ordered a 
continuous glucose monitor as part of the enrollees diabetes treatment plan. Based on this information, we 
decided that Medicare rules for coverage of the provided device have not been met. Therefore, we decided that 
the Plan does not have to pay for the continuous glucose monitor provided on May 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator trial (Percutaneous implantation 
of neurostimulator electrode array, epidural) (65650). 
 
You asked the Plan to pre-approve spinal cord stimulator trial. You say that the enrollee was found to be a good 
candidate for the trial and possible implant if the trial is successful. The Plan denied your request. The Plan 
says under Medicare guidelines, the request is not medically necessary. 
 
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 spinal cord stimulator trial. 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 had epidural steroid injections and RFA of medial 
branches. He takes Oxycodone and Gabapentin. He has psychological clearance for a SCS trial. His MRI 
shows spinal stenosis as well as foraminal stenosis. He has not had prior spine surgery. He does not have an 
evidence-based indication for a SCS trial. Therefore, the request is deemed 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 spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal cord stimulator trial (Percutaneous implantation of neurostimulator 
electrode array, epidural) (65650).