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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee asked for a skilled nursing facility 
admission. The enrollee had a change in behavior. The Plan denied your request. The Plan says the request 
does not show why the enrollee need this skilled nursing facility admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you do not feel like you are ready to go home. You 
have problems operating your wheelchair and cannot use your walker at all as it is too difficult. The Plan 
denied your request. The Plan says you are not progressing, have plateaued, and therapy has been discontinued. 
There is no indication to continue the SNF stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the basic radiation dosimetry calculation (77300) 
provided on October 4, 2022. 
 
You asked the Plan to waive the coinsurance for basic radiation dosimetry calculation. You say that you are 
unsure what services you are being billed for. You also say that you do not know if you were at the rendering 
facility on this date. The Plan denied your request. The Plan says that this claim was processed correctly. 
 
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 Plan did not include any medical records pertaining to the 
October 20, 2022, date of service and code in dispute. Without this necessary information, the Plan has not 
substantiated their argument that the claim processed correctly. Therefore, we decided that the Plan has to 
waive the coinsurance for the basic radiation dosimetry calculation (77300) provided on October 4, 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. 
 
Your complaint about the Plan paying the provider for billed services that were never supplied 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT solid tumor panel rendered on October 19, 
2022. 
 
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 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found that there is no documentation to support 
that the testing meets the Medicare criteria for coverage. The records do not document recurrent, relapsed, 
refractory, metastatic, or advanced stage III or IV cancer. The enrollee has not been previously tested with the 
same test using NGS for the same cancer genetic content and has decided to seek further cancer treatment (e.g., 
therapeutic chemotherapy) as required by Medicare rules. The services were therefore 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 pay for the Tempus xT solid tumor panel rendered on October 19, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab to reach their maximum 
level of function after having an amputation. The Plan denied your request. The Plan says that an IRF 
admission is not medically necessary, and the enrollee's needs can be met in other settings. 
 
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 does have complex functional impairments and active comorbidities. 
The enrollee's medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation 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 has to pre-
approve acute IRF admission and services.  
 
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 Freestyle Libre 3 sensors. 
 
You asked the Plan to pre-approve Freestyle Libre 3 sensors. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.   
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve Freestyle Libre 3 sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair or nonroutine service for durable medical 
equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes 
(K0739) and wheelchair component or accessory, not otherwise specified (K0108). 
 
You asked the Plan to pre-approve the wheelchair repairs. You say that please review all documents attached to 
justify the needed equipment. The Plan denied your request. The Plan says the available medical records do not support necessity of the service and item as defined by Medicare criteria as the reasonable useful lifetime of the 
equipment has been exceeded and that new equipment should be requested instead. 
 
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 wheelchair repairs. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no clear documentation that the 
wheelchair repair and wheelchair component or accessory at issue in this case meet all Medicare criteria for 
medically reasonable and necessary for the enrollee and that new equipment would not be more appropriate 
based on the reasonable useful lifetime of the equipment. The provided records in this case include conflicting 
information; one source states the enrollees mobility equipment was purchased on August 27, 2019, and 
another source states the equipment was purchased in February 2017. Given the lack of clarity on this issue, the 
wheelchair repair and wheelchair component or accessory at issue in this case do not meet all Medicare criteria 
for medically reasonable and necessary for the enrollee. The health Plan has stated that a request for new 
equipment would be reviewed if submitted. 
 
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 wheelchair repairs have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the repair or nonroutine service for durable medical equipment other than oxygen 
equipment requiring the skill of a technician, labor component, per 15 minutes (K0739) and wheelchair 
component or accessory, not otherwise specified (K0108).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure (LAAC) 
device. 
 
You asked the Plan to pre-approve placement of a LAAC. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that placement of a left atrial appendage closure device is 
only covered for certain indications. 
 
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 a LAAC. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has elevated risk of thromboembolic stroke due to atrial fibrillation 
and elevated CHADS2VASC score. Anti-coagulation is felt to represent an excessive risk of bleeding. While 
there is reference to consideration of the LAAC, there is no documentation of performance of an evidence-
based shared decision-making interaction. As such, guidelines would not support implantation of a LAAC in 
this setting. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure (LAAC) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 3 sensors. 
 
You asked the Plan to pre-approve Freestyle Libre 3 sensors. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve Freestyle Libre 3 sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on May 26, 2022. 
 
You asked the Plan to pay for initial hospital care (99223). You say that the claim should be reviewed for 
payment. The Plan denied your request. The Plan says the medical records submitted do not support medical 
decision making of high complexity. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 initial hospital care (99223). Our reviewer says that the 
documentation does not support procedure code 99223. Our reviewer found that the documentation does not 
support the encounter required decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) and drugs or medicaments dispensed in the 
office for home use (D9630) provided on January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
The services are not listed in your EOC as a covered benefit; therefore, it is not covered. Furthermore, the 
dentist you received services from does not participate in the supplemental dental vendor's network. Therefore, 
we decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) and drugs or medicaments dispensed in the 
office for home use (D9630) provided on January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the denial of the Intracept procedure is 
unwarranted and unsupported by the enrollee's current medical status and current peer-reviewed literature. The 
Plan denied your request. The Plan says the Intracept procedure is considered investigational (still being 
studied) as a treatment option for back pain 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found one double-blind randomized study has shown that improvement with the Intracept 
procedure was not clinically significant when compared with a sham procedure. Additional studies suggest that the Intracept procedure may be more effective for low back pain than conservative treatment. Limitations of the 
published medical literature include a limited number of studies, industry funding of the studies, and a high risk 
of bias from lack of controls. Additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. Current medical literature indicates that the Intracept procedure is 
investigational at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64629, 64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. The Plan denied your request. The Plan says this 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 an ILR. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, 
or any other apparent indication for an implantable cardiac monitor. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an implantable cardiac monitor in this 
enrollees 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 an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator for scoliosis (code E0744) 
provided on November 20, 2022. 
 
You asked the Plan to pay for a neuromuscular stimulator for scoliosis. The Plan denied your request. The Plan 
says a neuromuscular stimulator for scoliosis is not covered for the documented diagnosis. 
 
The Plan follows Medicare rules.  
 
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 a neuromuscular stimulator for scoliosis. 
Our reviewer says that the requested neuromuscular stimulator for scoliosis is not medically necessary. Our 
physician reviewer found that the enrollee has a history of chronic pain, degenerative disc disease (DDD), and 
muscle spasms, and scoliosis. Neuromuscular electrical stimulation (NMES) of paralyzed muscles can be used 
to restore or replace motor function in individuals who have upper motor neuron damage from causes such as 
stroke or spinal cord injury (SCI). In some conditions, such as stroke or incomplete SCI, NMES may be part of 
a therapy regimen that helps restore volitional movement and function. In this case, the neuromuscular 
stimulator for scoliosis at issue in this case does not meet the Medicare NCD coverage criteria. 
 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 neuromuscular stimulator for scoliosis have not been met. Therefore, we 
decided that the Plan does not have to pay for a neuromuscular stimulator for scoliosis (code E0744) provided 
on November 20, 2022.