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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need to get to 
medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
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 12 trips per year.  
 We looked at your request, the records in the case file, and the rules. 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 pre-approve additional routine transportation trips (A0120).
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. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
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 you do not have complex nursing or rehabilitation needs. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 5, 2021, to 
September 14, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim was underpaid. The Plan denied your request. The Plan says the billed secondary diagnosis of G96.6 
(cerebral edema) is not supported in the medical record, resulting in a lower DRG being paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the secondary diagnosis of G96.6 (cerebral edema). 
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 the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the secondary diagnosis of G96.6 (cerebral edema) is not supported in 
the medical record. Our physician reviewer found that cerebral edema can result from a variety of 
derangements. The major types include vasogenic, cellular, osmotic, and interstitial. Vasogenic cerebral edema 
refers to the influx of fluid and solutes into the brain through an incompetent blood-brain-barrier (BBB). This is 
the most common type of brain edema and results from increased permeability of the capillary endothelial 
cells, the white matter is primarily affected. In this case, there was no evidence of cerebral edema. No 
documentation of symptoms related to cerebral edema such as headache, altered level of consciousness, visual 
disturbances, changes in pupils, or seizure activity was not noted in the record.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 5, 2021, to September 14, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test provided to the enrollee on June 
15, 2022. 
 You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not considered standard of care. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the use of molecular profiling for squamous cell cancer of the skin is not a standard of care. Its use is 
not supported by the National Comprehensive Cancer Network (NCCN) guidelines. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the DecisionDx-SCC test provided to the enrollee on June 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that given the size of the enrollee's hernia, they will require 
bilateral posterior component separation in addition to preoperative Botox injections as their best chance at 
fascial closure. The Plan denied your request. The Plan says the clinical value and effectiveness of Botox in the 
setting of ventral hernia have 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 Botox. Our reviewer says that Botox is 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is 
insufficient support in the medical for the use of Botox to assist in the closure of a ventral hernia. Our reviewer 
also found that the documentation does not support that Botox is safe and effective for the enrollee. 
 
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 (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection of aflibercept (J0178) for 
treatment of age-related macular degeneration provided on September 7, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. You say that your EOC states there is a $0 
copayment for vision care. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
The purpose of the office visit with your ophthalmologist was for the injection. Therefore, the cost-share 
applied to the injection. 
 
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 20% 
coinsurance for Medicare Part B Prescription Drugs.  
 
You have been asked to pay $373.90 for an injection (Allowed Amount $1,869.48  20% coinsurance = 
$373.90). This item/service falls within the Medicare Part B Prescription Drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan.  
 This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an injection of aflibercept (J0178) for 
treatment of age-related macular degeneration provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance for sleep apnea to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the oral appliance. You say that the requested device is medically necessary. 
You say that you have tried a continuous positive airway pressure (CPAP) machine with no success. You also say that this is for your sleep apnea. The Plan denied your request. The Plan says the request was denied 
correctly. 
 
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 confirmed there are 
network providers available who can provide the item at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve 
an oral appliance for sleep apnea to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has problems with 
nocturnal hypoglycemia. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires 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 requested 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications 
established in the applicable LCD. 
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not medically reasonable and necessary. Our physician reviewer 
found that the enrollee has documented radiculopathy. The LCD criteria requires no other probable pain generator present. Therefore, the requested injections are 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
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 needs SNF care. The Plan denied your 
request. The Plan says the services required do not require daily inpatient skilled nursing and/or therapy 
services as there is no change in function that needs daily skilled therapy services. 
 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 that 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
June 18, 2022, to June 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you did not want to go to 
the hospital because you don't have money to pay these bills and that your insurance paid some bills, but you 
do not have money to pay the rest. 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 for in-network, 
inpatient hospital care you must pay a $320 copayment per day for days 1 to 5 and $0 copayment per day for 
days 6 and beyond.  
 
 
  
You have been asked to pay $1,600 ($320/day x 5 days = $1,600) for inpatient hospital care. This item/service 
falls within the inpatient hospital care 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 
inpatient hospital care provided from June 18, 2022, to June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) (99183), full body 
(G0277). 
 
You asked the Plan to pre-approve HBOT. You say that requested service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that use of hyperbaric oxygen (HBO) therapy is covered 
as adjunctive therapy only after there are no measurable signs of healing for at least 30days of treatment with 
standard wound therapy and must be used in addition to standard wound care. 
 
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 HBOT. Our reviewer says that the 
requested HBOT is not medically necessary. Our physician reviewer found the provided documentation 
indicates that the wound has not failed an adequate course of standard wound therapy since the wound has reduced in size by over 50% given the measurements available. The reviewer found that the documentation 
does not indicate the enrollee's wound has no measurable signs of healing for at least 30days of treatment with 
standard wound therapy. Therefore, the reviewer found that the requested HBOT is not medically reasonable or 
necessary 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 HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy (HBOT) (99183), full body (G0277).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29445-59 billed for June 6, 2022. 
 
You asked the Plan to pay for procedure code 29445. The Plan denied your request. The Plan says this code is 
not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 29445 is "Application of rigid total contact leg cast". 
 
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 procedure code 29445. Our reviewer says that the use of 
code 29445 is not supported by the records provided. Our reviewer found that the procedure report documents "culture and debridement on right leg with multilayer compressive Unna boot boot applied". In this case, there 
is a more appropriate code to report for an Unna boot, and per Medicare guidelines "When both a debridement 
is performed and an Unna boot is applied, only the debridement may be reimbursed. If only an Unna boot is 
applied and the wound is not debrided, then only the Unna boot application may be eligible for 
reimbursement". The documentation does not support total contact cast (TCC), which if documented correctly, 
would be separately reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 29445 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 29445-59 billed for June 6, 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 you strongly disagree with the denial for admission 
to an IRF. The Plan denied your request. The Plan says that that the coverage criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has complex functional impairments. The 
documentation also shows that the enrollee would require physiatry oversight during neurorehabilitation as the 
enrollee is still requiring restraints intermittently. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient services to be provided in a tertiary facility. 
 You asked the Plan to pre-approve the outpatient services. You say that you have been seeing this provider for 
5 years. You say that you feel comfortable with them. You say that you need a hearing evaluation and need to 
see this provider as soon as possible for your ear issue. The Plan denied your request. The Plan says the records 
available do not support a health need for a higher level of care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 outpatient services. Our reviewer 
says that the requested tertiary care is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the plan has approved an audiology evaluation at a non-tertiary provider. The 
reviewer found that the documentation does not establish the medical necessity and reasonableness, as defined 
by Medicare rules, of the requested tertiary care. Therefore, the reviewer found that the requested tertiary care 
is not 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 the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient services to be provided in a tertiary facility.