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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get into an IRF as soon as possible. The 
Plan denied your request. The Plan says the enrollee is without acute medical needs. 
 
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 an IRF admission is not medically necessary based on medical stability and lack 
of medical complexity, and lack of rehab nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Octreotide injection. 
 
You asked the Plan to pre-approve Octreotide injection. You say that the requested Octreotide injection is 
medically necessary. The Plan denied your request. The Plan says that the requested Octreotide injection is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Octreotide injection. Our reviewer says 
that the requested Octreotide injection is medically necessary. Our physician reviewer found the requested use 
of Octreotide is not FDA-approved for the enrollee's diagnosis. The use of Octreotide is supported by clinical 
research that appears in a CMS-approved medical journal. There are limited treatment options and Octreotide 
has the most data to support showing significant increase in hemoglobin and decrease in bleeding episodes and 
transfusion requirements. The documentation supports that Octreotide is safe and effective and reasonable and 
necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Octreotide injection have been met. Therefore, we decided that the Plan has to 
pre-approve Octreotide injection.  
 
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 home humidifier. 
 
You asked the Plan to pre-approve a home humidifier. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item statutorily non covered by Medicare. 
 
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 home humidifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services (V5011, V5160, V5253, V5364) 
provided on November 30, 2021. 
 
You asked the Plan to pay for hearing aid services. You say that you did not know you needed to register or 
that your provider was out-of-network. The Plan denied your request. The Plan says the provider in this case is 
not part of the Plan's specified routine hearing vendor network. Out-of-network hearing aid services are not 
covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received through the Plans specified routine hearing vendor network.  
 
 
 We looked at the file and the Plan's rules. The provider in this case is not part of the Plans hearing network. 
Based on this information, we decided that the Plan's rules for coverage of hearing aid services have not been 
met. Therefore, we decided that the Plan does not have to pay for the hearing aid services (V5011, V5160, 
V5253, V5364) provided on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wixela Inhub aerosol. 
 
You asked the Plan to pre-approve Wixela Inhub. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wixela Inhub aerosol.  
 Benefits for Wixela Inhub may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 25105 (excision of ganglion, wrist) and 25112 (wrist joint 
arthrotomy). Code 25105 is a column II code with a modifier indicator of 1 when billed with column I code 
25112. Code 25105 was not billed with an appropriate modifier to allow for separate payment. The provider also billed code 64721 (carpal tunnel surgery). Code 64721 is a column II code when billed with 
column I code 25105. Given that code 25015 is not covered, code 64721 is also not payable. The billing of the 
-59 modifier does not apply, as the code is unable to be billed separately from the non-covered column I code. 
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary. 
The Plan denied your request. The Plan says these are convenience items and are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary. The Plan 
denied your request. The Plan says the requested Botox 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 Botox. Our reviewer says that the 
requested Botox is not medically necessary. Our physician reviewer found based on the medical records 
provided and the Medicare-approved major drug compendia there is no documentation that the enrollee meets 
the Local Coverage Determination (LCD): Botulinum Toxins (L38809) criteria for the requested Botox. 
Gastroparesis is not recognized in the LCD or the Medicare-approved major drug compendia as a medically 
accepted indication for Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 27486 and 27350 are not supported. 
 
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 27486 is revision of total knee arthroplasty, with or 
without allograft; 1 component. The definition of code 27350 is patellectomy or hemipatellectomy. 
 
We find that CPT coded 27486 and 27350 are not supported in the medical record. Specifically, there is no 
documentation of revision of a total knee arthroplasty with or without allograft for 1 component to support 
code 27486. There is no documentation of a patellectomy or hemipatellectomy to support code 27350. Based 
on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 15, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on November 17, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF admission 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 the provided documentation does not indicate that the enrollee has complex nursing 
or rehabilitation needs.  The reviewer found that while the enrollee has a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 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. Therefore, the reviewer found that the IRF admission is 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete series dental x-rays (code D0210) and the 2D 
oral/facial radiographic image (code D0350) you received on date of service December 2, 2021. 
 
You asked the Plan to pay for codes D0210 and D0350. You say that you do not believe this dental provider 
was properly vetted and falsely advertised these dental services. The Plan denied your request. The Plan says 
the 2D oral/facial radiographic image (code D0350) you received is not a covered benefit under your plan.  In 
addition, you already exhausted your benefit for complete series x-rays with a separate claim billed for date of 
service December 2, 2021. 
 
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. This benefit includes coverage 
only for those dental services listed in your Mandatory Supplemental Dental Benefit chart.  In addition, complete series dental x-rays are only covered once every five years. 2D oral/facial radiographic 
image (code D0350) is not listed as a covered service and your plan has already paid for one complete series x-
ray within the 5-year period. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for complete 
series dental x-rays (code D0210) and the 2D oral/facial radiographic image (code D0350) you received on 
date of service December 2, 2021.  
 
Your complaint about the providers false advertising and provision of unnecessary services is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services (A0429, A0425) provided on 
July 12, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary 
and were billed appropriately. The Plan denied your request. The Plan says that this claim was billed without a 
required diagnosis code. 
 
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. Specifically, the case file forwarded by the Plan does not include the original 
claim that was submitted for review. Without this original claim, we cannot verify how these services were 
billed. In addition, there is no governing Medicare rule for the location of these services that regulates which 
diagnosis codes are appropriate to bill on ambulance claims. Therefore, we decided that the Plan has to pay for 
the ambulance transportation services (A0429, A0425) provided on July 12, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit provided on June 3, 2021. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says payment is included in the 
surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the requested visit is included in the payment for the 
global surgery procedure (27265) provided on June 1, 2021. Separate payment cannot be made. Based on this 
information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided 
that the Plan does not have to pay for the visit provided on June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the criteria have 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 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 indicates that the enrollee does not use insulin with at least three daily injections, and 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 CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 Day 
Sensor continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2781, V2782, V2750, V2745) 
provided on July 12, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you were unaware that you were not a contracted 
provider and needed prior authorization. The Plan denied your request. The Plan says the provider in this case 
is not part of the Plan's network. Supplemental vision care is only covered when performed by a participating 
provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services only when they are received from a participating provider. 
 
We looked at the file and the Plan's rules. The provider in this case is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses (V2020, V2781, V2782, V2750, V2745) provided 
on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
November 2, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and scaling and root planing (D4341 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that the dental office advised there are no other 
in network dentists in the area. You also say that you need help paying for these services. The Plan denied your 
request. The Plan says the crown and scaling and root planing are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested crown and scaling and root planing are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) and scaling and root planing (D4341 x 4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing rendered on September 27, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly.  
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed 
adjacent to the CPT code for GeneSight testing. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX 
Z-Code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on 
September 27, 2021.