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

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. 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 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have documented skilled therapy needs. The enrollee is 
functioning below her baseline. Skilled services for strength training, transfer training, caregiver training and 
durable medical equipment evaluation is medically necessary and reasonable.  
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 14, 2022, to 
January 20, 2022, 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 the 
diagnosis was documented by multiple physicians. The Plan denied your request. The Plan says the diagnosis 
was not clinically validated. 
 
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 diagnosis code E87.1, defined as hypo-osmolality 
and hyponatremia. 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 physician reviewer found that hyponatremia is the most commonly 
encountered and important electrolyte imbalance that can be seen in isolation or as is most often the case, as a 
complication of other medical illnesses (e.g., heart failure, liver failure, kidney failure, pneumonia, cancer). In 
those whose hyponatremia has a known duration of greater than 48 hours, treatment must be calibrated to avoid 
osmotic demyelination syndrome (ODS), which may result from overly rapid correction. Per the 
documentation, it is noted that hyponatremia was documented as a diagnosis and the enrollee was given salt 
tabs. However, there was no documentation of a possible cause or reason for this diagnosis. The review has 
determined that the records support the billed diagnosis.  
 
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 January 14, 2022, to January 20, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75743 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 75743. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 75743 is bundled into payment for 
code 37211. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 75743 is a column II code to column I code 37211. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 75743 
billed for date of service April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous device. 
 
You asked the Plan to pre-approve the insertion of interlaminar/interspinous device. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 insertion of 
interlaminar/interspinous device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the Interlaminar distraction 
devices are experimental. More research is needed before coverage can be approved. 
 
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 insertion of interlaminar/interspinous device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a regadenoson injection and a SPECT scan 
provided on June 17, 2022. 
 
You asked the Plan to waive the cost share for a regadenoson injection and a SPECT scan. You say that these 
bills should not be this much money, and you should not be paying either amount. You also say you are 
struggling to pay bills and you do not want to pay either amount. 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 10% 
coinsurance of the cost for Medicare Part B prescription drugs. Your contract with the Plan also clearly says 
that you must pay a $150 copayment for Medicare-covered diagnostic radiology services (not including x-
rays).  You have been asked to pay $27.06 for the regadenoson injection ($270.60 x 10% coinsurance = $27.06). You 
have also been asked to pay $150 for the SPECT scan. The total you owe is $177.06 ($27.06 + $150 = 
$177.06). The regadenoson injection falls within the prescription drugs benefit category. The SPECT scan falls 
within the diagnostic radiology services 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 cost share 
for a regadenoson injection and a SPECT scan provided on June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on April 06, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you cannot afford this 
charge. 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 $265 
copayment for Ambulance services. 
 
You have been asked to pay a $265 copayment for ambulance transport. This item/service falls within the 
Ambulance services 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 ambulance transport 
provided on April 06, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on May 4, 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 that the services were not billed 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. the Plan references Local Coverage Determination (LCD) L35024 in their 
determination; however, this LCD is not binding for the state of Massachusetts where the single-source testing 
was performed. The Plan has not provided any documentation or valid Medicare rules to support that the 
services are not covered. Therefore, we decided that the Plan has to pay for the laboratory services rendered on 
May 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for individual therapy provided on August 4, 
2022. 
 
You asked the Plan to waive the copayment for individual therapy. You say that you are disputing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 
copayment for outpatient mental health care.  
 
You have been asked to pay $20 copayment for individual therapy. This item/service falls within the outpatient 
mental health 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 individual therapy 
provided on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and sphere, bifocal lenses (V2200) 
provided on June 17, 2022. 
 
You asked the Plan to pay for the routine frames and lenses. You say that you have eye issues and needed new 
glasses. The Plan denied your request. The Plan says you were not yet eligible for coverage of routine eyewear.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once in a rolling calendar year since your last date of service. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that routine eyewear was 
previously covered on August 24, 2021.  Based on this information, we decided that the Plan's rules for 
coverage of the routine frames and lenses have not been met. Therefore, we decided that the Plan does not have 
to pay for the frames (V2020) and sphere, bifocal lenses (V2200) provided on June 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Aer 200MCG. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Trelegy is a self-administered drug and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Aer 200MCG.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that you have mobility issues. The Plan 
denied your request. The Plan says you do not require special fittings and adjustments. 
 
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered under certain 
medical 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 the requested wheelchair. Our physician 
reviewer found that you had a stroke and have increased tone in the affected right arm. The submitted 
documentation is a check mark document. It does not provide adequate documentation for the medical 
necessity of an ultralight wheelchair, including individual fittings that cannot otherwise be accommodated. 
Therefore, the requested wheelchair 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 requested wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an ultra-lightweight manual wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after October 28, 
2022. 
 
You asked the Plan to pre-approve SNF care after October 28, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
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 pre-approve SNF care after October 28, 2022. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found continued daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of the enrollees condition. The enrollees care 
needs, as a practical matter, can 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 after October 28, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after October 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided from June 7, 
2022, to June 30, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you believe you are not 
supposed to pay a copayment for outpatient physical therapy. You are appealing, asking that consideration be 
given to your age and limited income. 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 $35 
copayment for in-network physical therapy in-person visits.  
 
You have been asked to pay $280 for physical therapy ($35 copayment/visit x 8 visits = $280). This 
item/service falls within the physical therapy 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 physical therapy provided from June 7, 2022, to June 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on March 01, 2022, to April 01, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you are being 
over charged and shouldnt have to pay this. 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 $188 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $188 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the Skilled nursing facility (SNF) 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. You have been asked to pay $188 per day for days 21 through 100 of your 
SNF care stay. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing 
facility (SNF) care provided on March 01, 2022, to April 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pairing or cutting of benign hyperkeratotic lesion (11057) 
provided on July 7, 2022. 
 
You asked the Plan to pay for the routine foot care. You say that this service is for medical services. You say 
that it is not routine. You say that you have only every paid a $35 copayment for this service. You also say that 
you cannot afford to pay this bill. The Plan denied your request. The Plan says routine foot care is not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the pairing or 
cutting of benign hyperkeratotic lesion (11057) provided on July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88112, 88305, 88312, 88361) provided 
on January 20, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical 
component (TC) of a physician pathology service provided to an inpatient or outpatient. 
 
We looked at the file and Medicare rules. The services at issue were provided to a hospital outpatient but were 
not billed with a modifier to indicate only the professional component, not the technical component, are billing 
billed. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88112, 88305, 
88312, 88361) provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed for date of service February 10, 
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 are not covered. 
 
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, we have confirmed that code 93620 
is a column II code to column I code 93656. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  
 
The rules say that post-surgical services are included in the global surgical package. The file shows that 
procedure code 93656 was related to and billed within 90 days of major procedure 33208 billed on January 25, 
2022. Payment for these services is included in the global surgical package. 
 
Therefore, we decided that the Plan does not have to pay for the surgical services billed for date of service 
February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested Vertiflex procedure is 
considered experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertilflex devise is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.