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

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 28, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $375 
copayment for outpatient surgery/Medicare-covered surgery or other services provided to you at an outpatient 
hospital.  
 
You have been asked to pay a $375 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery or other services provided to you at an outpatient hospital 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 an outpatient surgery provided on July 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove three additional routine transportation miles. 
 
You asked the Plan to preapprove the three additional routine transportation miles. You say that you are 
requesting additional transportation coverage due to your trip from your residence to the hospital. The Plan 
denied your request. The Plan says the service is a covered benefit, but you have exceeded the benefit limits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles per one-way trip.  
 We looked at your request, the records in the case file, and the rules. Specifically, the shortest route is 53.2 
miles which exceeds the benefit milage limit. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to preapprove three additional routine transportation miles.
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 the therapeutic continuous glucose monitor (CGM). You say that you are 
appealing the denial of the CGM to help control the enrollee's diabetes mellitus and apparent hypoglycemic 
unawareness. The Plan denied your request. The Plan says the enrollee does 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve the CGM. You say that you disagree with the denial for a CGM. 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 you do not use insulin with at least 
three daily injections and you do not require frequent self-adjustment of your 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 a therapeutic CGM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for obstructive sleep apnea adult pediatric provided on 
September 07, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for obstructive sleep apnea adult pediatric. You say that you are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider. In most cases, care the enrollee receives from an out-of-network provider (a provider who is 
not part of the plans network) will not be covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for obstructive sleep apnea adult pediatric provided on 
September 07, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network SNF care. You say that the enrollee needs skilled nursing 
and therapy to be able to safely return home. The Plan denied your request. The Plan says based on Medicare 
guidelines, your request to use an out-of-network provider for your services does not meet the requirements for 
approval. 
 
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 
SNF care to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for a new patient (99203) provided on August 
9, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee has not been 
seen in the last three by sub-specialty Radiation Oncology. You also say that a new patient code is therefore 
eligible for reimbursement. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. 
Typically, 30 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the provided documentation 
indicates that this enrollee previously received professional services from this physician and billing group 
within the last 3 years. Based on this information, we decided that Medicare rules for coverage of the 
evaluation and management service have not been met. Therefore, we decided that the Plan does not have to 
pay for the office visit for a new patient (99203) provided on August 9, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 in one day, the enrollee moved to very near a home care level of rehabilitation. The 
enrollee does not require intensive rehabilitation services or frequent physiatry oversight. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay provided on February 19, 2022, to March 
02, 2022. 
 
You asked the Plan to pay for an inpatient stay. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an inpatient stay 
provided on February 19, 2022, to March 02, 2022.
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 member's current condition causes them to be a 
fall risk and an inpatient rehabilitation would help them get stronger, so they are able to get around more safely. 
The Plan denied your request. The Plan says services requested can be provided in other settings, such as a 
skilled nursing facility or home health 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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2330 and D2331) provided on July 
20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe this should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental allowance amount was exhausted on date of service July 18, 2022. Therefore, we 
decided that the Plan does not have to pay for resin-based composites (D2330 and D2331) provided on July 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of the CardioMEMS device 
has not been demonstrated in the peer-reviewed literature. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time the CardioMEMS system would not be considered medically appropriate 
and necessary in your 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 CardioMEMS device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device (CPT 
code 33289).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venofer. 
 
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 intravenous iron therapy 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 submitted records do not document 
that the enrollee has iron deficiency anemia. The hemoglobin and hematocrit levels were normal on the latest 
records dated January 13, 2023. The criteria for coverage are not met and the Venofer is not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Venofer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve the CGM. You say that you disagree with the denial for a CGM. 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 you do not use insulin with at least 
three daily injections and you do 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 CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic CGM.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on August 01, 2022. 
 
You asked the Plan to pay for a physical therapy visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a physical therapy visit 
provided on August 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service July 29, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that radiology reports were submitted. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service July 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
(72148) 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you want the Plan to approve the 
requested service. The Plan denied your request. The Plan says conservative treatment has not been initiated 
and the request is, therefore, not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an MRI can be covered if the patient has not 
responded to a reasonable trial of conservative management lasting at least four weeks. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is not 
noted to have any "red flag" indications on exam (as defined by the LCD). There was otherwise no 
documentation of any course of conservative therapy at this time. There was also no evidence that "aggressive 
treatment" is under consideration at this time (based on the LCD definition). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device. 
 
You asked the Plan to pre-approve the Minuteman device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the 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 the Minuteman device. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Minuteman is an inter-spinous spacer and fusion device for fixation and 
stabilization of thoracic, lumbar and sacral spine. The procedure is indicated for patients who have back or leg 
pain due to degenerative disc disease, spondylolisthesis, tumor or trauma. The Medicare criteria for reasonable 
and necessary are not met because use of this device as a stand-alone procedure (and not part of a spine surgery 
by a spine surgeon) has not been shown to be safe and effective in long term studies. This device is not 
approved for use in a stand-alone procedure as requested by the enrollee's pain practitioner provider. 
 
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman device.