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

 
We decided that the Plan does not have to waive the cost share for an outpatient surgery provided on February 
24, 2022. 
 
You asked the Plan to waive the cost share for an outpatient surgery. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $1,000 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 
deductible which applies to outpatient surgery. You are being asked to pay $378.54 towards your $1,000 
deductible. This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery 
was received on February 24, 2022. Therefore, we decided that the Plan does not have to waive the cost share 
for an outpatient surgery provided on February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
supply. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 supply. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 a Freestyle Libre 3 CGM supply.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from September 17, 2022, to October 16, 
2022. 
 You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your 
request. The Plan says that the SNF stay was not medically necessary. 
 
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 pay for 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 did not have documented skilled nursing or skilled therapy needs. 
Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition. 
 
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 pay for SNF care provided from September 17, 2022, to October 16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for DermTech Pigmented Lesion Assay (PLA) testing (0089U) provided 
on December 2, 2021. 
 
You asked the Plan to pay for the testing. You say that this is a covered test which was medically necessary. 
The Plan denied your request. The Plan says that this test is was not medically necessary for this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has pigmented lesion suspicious melanoma. Use of the PLA improves patient care by 
using genomic assessments to minimize avoidable surgical procedures on benign lesions, enrich the population 
of melanomas diagnosed, and decrease downstream costs of late-stage melanoma diagnoses. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
DermTech Pigmented Lesion Assay (PLA) testing (0089U) provided on December 2, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivestym (Q5110). 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the requested use is not approved by the 
FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our physician reviewer 
found the requested use of Nivestym is not FDA-approved for the enrollees diagnosis because absolute 
neutrophil count (ANC) is adequate, but also progression on current regiment. The use is not supported by one 
of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid 
Services (CMS)-approved medical journal (see appendix for list of CMS-approved journals). 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Nivestym (Q5110).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from August 30, 2022, 
to September 13, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed of how long 
you were going to be at the SNF, and you did not have a ride when you were advised of your discharge date. 
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 $20 per 
day for days 1 to 20 and an $80 copayment per day for days 21 to 44 for each SNF admission.  
 
You have been asked to pay a total copayment of $300 for a SNF stay ($20 per day x 15 days = $300). This 
item/service falls within the skilled nursing facility 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 a SNF stay provided from August 30, 2022, to September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found there is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide 
(CO2 retention. If this enrollee does have chronic CO2 retention, may benefit from bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. The denial is upheld. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from September 15, 2022, to October 14, 
2022. 
 You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your 
request. The Plan says that the SNF stay was not medically necessary. 
 
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 pay for 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 did not have documented skilled nursing or skilled therapy needs. 
Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition. The enrollee's care need could, as a practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from September 15, 2022, to October 14, 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 enrollee needs LTACH level of care. The Plan 
denied your request. The Plan says the enrollee does not need 3 hours a day of therapy 5 days a week, medical 
illnesses are stable, and does not need a rehabilitation physician to monitor the strengthening program three 
times a week, and there is no need for an intensive team to oversee care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee cannot use a prosthesis at current time and cannot participate in or 
benefit from intensive therapy. The enrollee has shown a very limited response to daily skilled therapy and 
does not require 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 occupational therapy (OT) sessions. 
 
You asked the Plan to pre-approve the therapy services. You say that you are making progress and believe that 
you need more occupational therapy. The Plan denied your request. The Plan says you are making progress and 
believe that you need more occupational therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the current condition or to prevent or slow further deterioration. The enrollee has had 
instruction and is noted to be compliant in her home exercise program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 10 occupational therapy (OT) sessions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an magnetic resonance imaging (MRI) 
provided on November 14, 2022. 
 
You asked the Plan to waive the copayment for an magnetic resonance imaging (MRI). 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 $100 
copayment for outpatient diagnostic tests/advanced imaging service. 
 
You have been asked to pay a $100 copayment for an magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests/advanced imaging service 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 magnetic resonance imaging (MRI) provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the shoulder x-ray and the dexamethasone 
sodium phosphate injection provided by an in-network provider on September 21, 2022. 
 
You asked the Plan to waive the cost sharing for the x-ray and the injection. You say that you were not aware 
of the cost sharing for these services. 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 $20 
copayment for each in-network x-ray service, and a 20% coinsurance for in-network Medicare Part B 
chemotherapy drugs, associated administration services, and all other Medicare Part B drugs. 
 
 You have been asked to pay a $20 copayment for the x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $0.45 
coinsurance for the injection ($2.24 allowed amount x .20 = $0.45) This item/service falls within the Medicare 
Part B prescription drugs benefit category. You have been asked to pay a total cost share of $20.45 for the x-
ray and the injection. 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 cost sharing for the shoulder x-ray and the 
dexamethasone sodium phosphate injection provided by an in-network provider on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional level of facet injection. 
 
 
You asked the Plan to pre-approve the injection. You say that that utilization criteria levels diagnostic 
injections to 2 levels at a session.  No unusual circumstances are noted in the progress notes. Therefore, only 2 
levels are deemed medically reasonable and necessary. The Plan denied your request. The Plan says the request 
for more than two levels of facet injection 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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found  
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an additional level of facet injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex lumbar interspinous decompression device 
(22867 and 22868). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the requested Coflex lumbar 
interspinous decompression device at L2-3 and L3-4, in this case, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Coflex lumbar interspinous decompression device (22867 and 22868).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an InterStim sacral nerve stimulator (64590). 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is no provided voiding diary, or documentation of test stimulation 
completion. 
 
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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records do not show that a voiding diary has been provided or that a test stimulation 
(CPT 64561) has been performed.  
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an InterStim sacral nerve stimulator (64590).