Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have chronical health issues, but your 
doctor says you do not meet the criteria for this benefit. The Plan denied your request. The Plan says based on 
the information provided, there is no documentation that you meet all three criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not provided. Without medical records, we are unable to determine if you 
meet the coverage criteria for SSBCI benefits. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (64628 and 62629). 
 
You asked the Plan to pre-approve the thermal destruction of intraosseous basivertebral nerve. You say that the 
services are medically necessary. The Plan denied your request. The Plan says these services are considered 
experimental. 
 
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 thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found documentation was/is lacking regarding reasonably 
detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary 
generators of the enrollees chronic persistent pain. Documentation does not support actual formal surgical 
ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the thermal destruction of intraosseous 
basivertebral nerve (64628 and 62629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI) benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are deemed necessary for the SSBCI 
attestation, and you say you are chronically ill. The Plan denied your request. The Plan says there is no 
documentation that the enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefits.
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 enrollees ability to regain maximum 
function could be seriously jeopardized by applying the standard timestamp for approval/admission. The Plan 
denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately 
treated in the current hospital where acute and critical care is necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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. 
 
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: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the Omidria medication provided on October 17, 
2022. We also decided that the Plan does not have to waive the coinsurance for the Omidria medication 
provided on September 7, 2022.  
 You asked the Plan to waive the coinsurance for the Omidria medication. You say that this cost sharing should 
be included in the outpatient surgery copayment. The Plan says that the cost sharing was applied 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 enrollees must pay 20% coinsurance for Medicare Part B drugs.  
 
We decided that the Plan has to reduce the coinsurance for the Omidria medication provided on October 
17, 2022.  
 
The Plan allowance for the Omidria medication provided on October 17, 2022, was $381.36. You are 
responsible to pay $76.27 for this service ($381.36 x 20% = $76.27). Based on the Plan contract, however, you 
cannot be asked to pay more than 20% coinsurance for Medicare Part B drugs. Therefore, we decided that the 
Plan has to reduce the coinsurance for the Omidria medication provided on October 17, 2022.  
 
We also decided that the Plan does not have to waive the coinsurance for the Omidria medication 
provided on September 7, 2022. 
 
The Plan allowance for the Omidria medication provided on September 7, 2022, was $388.40. You are 
responsible to pay $77.68 for this medication ($388.40 x 20% = $77.68). This item/service falls within the 
Medicare Part B prescription drug 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 
the Omidria medication provided on September 7, 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: Drugs
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 continuous glucose monitor. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been 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 indicates that the enrollee does not 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 continuous glucose monitor 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 pre-approve Tempus xF targeted genomic sequence analysis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of stage IV 
secondary malignant neoplasm of the liver and intrahepatic bile duct. The primary malignancy is 
adenocarcinoma of the lung with metastases to the brain. The documentation does not support that the coverage 
criteria for the Tempus xF Panel genetic testing in this case met the coverage criteria for genetic testing. This 
testing does not have Food and Drug Administration (FDA) approval or clearance, and an FDA-approved or -
cleared indication for use in this enrollee's cancer. 
 
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 pre-approve Tempus xF targeted genomic sequence analysis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is requesting IRF services. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you were recently diagnosed with 
diabetes and lost a lot of weight. You also say that you do not want to prick your finger with a needle. The Plan 
denied your request. The Plan says you do 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
2 continuous glucose monitor (CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 27, 2021, to 
October 1, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary 
for the enrollee. The Plan denied your request. The Plan says that prior authorization was not obtained before 
the services were rendered. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation indicates that the enrollee was admitted and treated with 
intravenous (IV) antibiotics, oxygen support, IV fluids, Lasix, and blood transfusions. The reviewer found that 
the enrollee's blood pressure dropped after admission. The reviewer found that due to the complexity and 
severity of the enrollee's condition at the time of admission and following failure of outpatient treatment, it was 
expected that the enrollee would require hospitalization that would likely cross 2 midnights. Therefore, the 
reviewer found that the inpatient care was medically reasonable and 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from September 27, 2021, to October 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-chek guide test strips. 
 
You asked the Plan to pre-approve Accu-chek test strips. You say that you disagree with the denial for Accu-
check test strips. The Plan denied your request. The Plan says that the enrollee's benefits do not cover the 
requested brand. 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. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-
sharing for the preferred brands or may limit the durable medical equipment (DME) to only those preferred 
brands and manufacturers, as long as they ensure that enrollees have access to all medically necessary 
(including non-preferred) DME products or brands. 
 
We looked at the file and Medicare rules. According to the EOC, Accu-chek is not a preferred brand and is not 
covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve Accu-chek guide test 
strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and related supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been 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 indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
CGM and related supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repair of nasal valve collapse with 
subcutaneous/submucosal lateral wall implant (30468). 
 
You asked the Plan to pre-approve a repair of nasal valve collapse with subcutaneous/submucosal lateral wall 
implant. You say that the services are medically necessary. The Plan denied your request. The Plan says the 
services are 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 a repair of nasal valve collapse with 
subcutaneous/submucosal lateral wall implant. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found infection, allergy, rhinitis, and 
polyps have not been eliminated as the primary cause of nasal obstruction, and the member had not received 
the full extent of medical treatment for symptoms prior to the ordering of the procedure. 
 
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 repair of nasal valve collapse with subcutaneous/submucosal lateral wall 
implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a repair of nasal 
valve collapse with subcutaneous/submucosal lateral wall implant (30468).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous spacer device (22869, 22870). 
 
You asked the Plan to pre-approve the interspinous spacer device. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 interspinous spacer device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is considered experimental. More research is needed to show 
safety and 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 the interspinous spacer device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an interspinous spacer device (22869, 22870).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nasal/sinus endoscopy, surgical, with frontal sinus 
exploration, including removal of tissue from frontal sinus, when performed provided to the enrollee on June 
22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 31276 is "Nasal/sinus endoscopy, surgical, with frontal 
sinus exploration, including removal of tissue from frontal sinus, when performed." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT code 31276 is not supported 
by the medical record. The record lists several procedures, including antrostomy and ethmoidectomy. The 
tissues submitted to pathology were uncinate and maxillary. The documentation does not support that a separately reportable endoscopic exploration of the nasal sinuses were performed during this encounter. 
 
We looked at this coder'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 pay for nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue 
from frontal sinus, when performed provided to the enrollee on June 22, 2022.