Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for a continuous glucose monitor (CGM) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve CGM supplies. You say that the requested supplies are a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage for OON care have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
supplies for a CGM to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed with special features. 
 
You asked the Plan to pre-approve a total electric hospital bed with special features. You say that this is 
medically necessary. The Plan denied your request. The Plan says this equipment is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed with special features.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an Optimizer Smart implantable pulse 
generator (0408T). 
 
You asked the Plan to pre-approve placement of an implantable pulse generator. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
service 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 placement of an implantable pulse 
generator. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found that cardiac contractility modulation remains the subject of multiple 
studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify 
clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical 
outcomes and benefit. 
 
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 placement of an implantable pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of an Optimizer Smart implantable pulse 
generator (0408T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met in an assisted living facility with home health services. The enrollee's needs can 
also be met in a long-term care facility with part-time skilled services. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for frames (V2020), lenses (V2100), anti-reflective coating (V2750), ultra-
violet lenses (V2755), and polycarbonate lenses (V2784) provided on August 2, 2022. 
 
You asked the Plan to pay for frames (V2020), lenses (V2100), anti-reflective coating (V2750), ultra-violet 
lenses (V2755), and polycarbonate lenses (V2784). You say that you were told by the Plan that this provider 
was in-network. You also say that you do not think that you received the $150 allowance for your glasses. The 
Plan denied your request. The Plan says that your billed amount was $534.95 with a discount of $319.99 ($150 
allowance applied to discount). The Plan also says that the provider billed the insurance $70 with a member 
responsibility of $144.96, in which you paid at the time of services. 
 
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 explanation of benefit submitted to us by the Plan shows the Plan denied for 
going to an out-of-network provider. The record shows the provider was in-network. However, for this appeal 
the Plan's argument was that they applied the $150 allowance. However, the Plan failed to provide any 
verification that they applied the $150 allowance. Without the evidence, we are unable to verify the Plan was 
correct in how they denied the appeal. Therefore, we decided that the Plan has to pay for frames (V2020), 
lenses (V2100), anti-reflective coating (V2750), ultra-violet lenses (V2755), and polycarbonate lenses (V2784) 
provided on August 2, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient care is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition they do not meet all the requirements. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for weakness, urinary tract infection, and COVID-19 infection. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. While the medical records support 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. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code(s) 88305. You say that your claim is not a duplicate to a claim 
previously submitted by and different provider. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service March 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a CPAP back-up battery. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery for a CPAP device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you never received the proper physical therapy and 
are unable to walk. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for revision of knee arthroplasty. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support 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. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied. 
 
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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 70480. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 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, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a visual field assessment, with concurrent real time data 
analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up 
to 30 days (0379T). 
 
You asked the Plan to pre-approve a visual field assessment, with concurrent real time data analysis and 
accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days 
(0379T). You say that the member does not have the option to visit an in-network provider, as this provider is 
the only provider in the world to render these services. You also say this service is not only medically 
necessary for the patient based on the submitted medical records, but is also a service that is covered by 
Medicare and many other health insurers. The Plan denied your request. The Plan says the requested service 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 visual field assessment, with concurrent 
real time data analysis and accessible data storage with patient initiated data transmitted to a remote 
surveillance center for up to 30 days (0379T). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not 
meet the requirements for this service. Our physician reviewer also found that the treating provider has 
recommended an existing and available medically appropriate alternative home test. Our physician reviewer 
also found that there is no documentation, that has been submitted to show that the patient is unable to perform 
that home test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of visual field assessment, with concurrent real time data analysis and accessible 
data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days (0379T) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a visual field assessment, 
with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a 
remote surveillance center for up to 30 days (0379T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says radiographic evidence does not support advanced hip arthritis. 
 
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 requested services. Our physician 
reviewer found that the enrollee has reported osteoarthritis of the right hip. The record provided does not 
include radiographic evidence of hip osteoarthritis. The record is insufficient to establish the medical necessity 
of the requested service for the enrollee. The elements of the coverage criteria are not satisfied.  The requested 
service is not recommended. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from an IRF to safely 
ambulate functional diseases and participate in activities of daily living in a reasonable time frame. You say 
that physical and occupational therapy will be provided to reduce risk for falls and to increase ability to tolerate 
therapy without rest breaks, while also regaining maximum level of function. The Plan denied your request. 
The Plan says an IRF admission is not medically necessary, and 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. Our 
physician reviewer found that the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as a skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for a continuous positive airway 
pressure (CPAP) device (A9270). 
 
You asked the Plan to pre-approve a battery backup for a CPAP device. You say that you need this device to 
operate your CPAP machine during power outages. The Plan denied your request. The Plan says Medicare does 
not allow payment for power generators or alternative power sources needed in the event of power outages. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery backup for a continuous positive airway pressure 
(CPAP) device (A9270).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from acute IRF with close 
medical monitoring due to the metabolic and cardiopulmonary demands of rehabilitation. The Plan denied your 
request. The Plan says based on Medicare guidelines and the information we have about the enrollee's 
condition they do not meet all the requirements. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for congestive heart failure, acute on chronic renal disease, and lower extremity wounds. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the medical records support 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. 
 
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 IRF admission and services.