Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for therapeutic continuous glucose 
monitor (CGM) (K0553) and receiver (K0554). 
 
You asked the Plan to pre-approve the supply allowance for therapeutic CGM and receiver. You say that you 
feel your quality of life would be unfairly impacted by losing your pre-existing monitor. You also say that you 
are out of sensors and need them as soon as possible. The Plan denied your request. The Plan says you do not 
meet the medical necessity guidelines for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the supply allowance for 
therapeutic CGM and receiver have not been met. Therefore, we decided that the Plan does not have to pre-
approve a supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) and receiver (K0554).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care such as at a skilled nursing facility. 
 
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 while the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services an IRF would provide. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is on a breathing tube and 
needs long term acute care. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested LTACH services do not meet the requirements for approval. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The health plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
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 criteria for admission to SNF have not been met. Skilled services can be provided on an 
intermittent outpatient basis, in a long-term care facility, or at the home with home health care 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 SNF 
care is not medically necessary. 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 a skilled nursing facility (SNF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation by stretcher van (T2005). 
 
You asked the Plan to pre-approve the non-emergency transportation by stretcher van. You say that you had 
recent joint surgery and now need stitches removed. You also say that you need to be transported by a stretcher 
to and from your appointment. The Plan denied your request. The Plan says this service is not covered. 
 
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 contract says that the routine transportation benefit does not cover transportation by stretcher.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve non-emergency transportation by stretcher van (T2005).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis services coded 88360 provided on 
May 14, 2021. 
 
You asked the Plan to pay for the morphometric analysis services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 88360 is morphometric analysis, tumor 
immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or 
semiquantitative, per specimen, each single antibody stain procedure; manual. 
 
We find that CPT code 88360 is not supported in the medical record. Specifically, the documentation shows 
that this is a duplicate service to the same services billed for the same date of service by a different provide of 
the same specialty. This means this is a duplicate claim and cannot be paid as billed. Based on this information, 
we decided that Medicare rules for coverage of the morphometric analysis services have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis services coded 88360 
provided on May 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinvanti. 
 
You asked the Plan to pre-approve Cinvanti. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this is a routine cost as part of a clinical trial and must be billed through Original 
Medicare.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Cinvanti as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Cinvanti.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on December 9, 2021. 
 
You asked the Plan to waive the copayment for MRI. You say that you didn't know the provider was out of 
network so it should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $285 
copayment for diagnostic radiology services performed by a provider other than your primary care physician.  
 
You have been asked to pay $244.59 which is less than the standard $285 copayment for MRI. MRIs fall 
within the Outpatient diagnostic tests and therapeutic services and supplies 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 MRI provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an ophthalmologist (99204), a 
scanning computerized ophthalmic diagnostic imaging (92134), a fundus photography with interpretation 
(92250), a fluorescein angiography (92235x2) and a visual field examination (92083x2) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and services with an ophthalmologist. You say that you do 
not agree with the denial and would like to request reconsideration. The Plan denied your request. The Plan 
says there are in network providers available who can supply the requested services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit with an ophthalmologist (99204), a scanning computerized ophthalmic diagnostic imaging 
(92134), a fundus photography with interpretation (92250), a fluorescein angiography (92235x2) and a visual 
field examination (92083x2) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 21, 2021. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are 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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, no payment is recognized 
for code 85060 furnished to hospital outpatients or non-hospital enrollees. This code was billed with a place of 
service 22 (outpatient hospital) which is not considered an appropriate place of service for this code. Based on 
this information, we decided that Medicare rules for coverage of the blood smear services have not been met. 
Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says despite multiple requests, records have not been received regarding this case. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of total knee arthroplasty for the enrollee. 
have been met. Despite multiple requests from the plan, no medical information about this request has been 
received.. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty for the 
enrollee.
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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 were admitted for hypotension and syncope. Medical problems are stable.  
 There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucala 100mg/ml syringe for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication is approved as add-on therapy to other maintenance asthma medications 
in the setting of severe asthma. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the provided 
records do not document that the enrollee is on any standard maintenance therapy for asthma control. The 
records only document use of an as-needed albuterol inhaler. 
 
 
 
 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nucala 100mg/ml syringe for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 13, 2021. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are 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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code is only used when 
physician interprets an abnormal peripheral blood smear for a hospital inpatient or a hospital outpatient, and the 
hospital is responsible for the technical component. This means this claim was billed incorrectly. Based on this 
information, we decided that Medicare rules for coverage of the blood smear services have not been met. 
Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve an over-bed table. You say that this is necessary for your condition. The 
Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that over-bed tables are not covered. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table (E0274).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zimmer Biomet spine, community tissue services, 
Intergo demineralized bone matrix (DBM) past, and Maxxeus Allograft. 
 
You asked the Plan to pre-approve Zimmer Biomet spine, community tissue services, Intergo DBM past, and 
Maxxeus Allograft. 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 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 Zimmer Biomet spine, community 
tissue services, Intergo DBM past, and Maxxeus Allograft. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found Intergo DBM 
allograft is expeprimental. Iliac crest autograft remains the gold standard. DBM is not needed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zimmer Biomet spine, community tissue services, Intergo DBM past, and 
Maxxeus Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Zimmer Biomet spine, community tissue services, Intergo demineralized bone matrix (DBM) past, and 
Maxxeus Allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation, low- level laser treatment and 
extracorporeal shock wave treatment provided from December 6, 2021, through January 24, 2022. 
 
You asked the Plan to pay for electrical stimulation, low- level laser treatment and extracorporeal shock wave 
treatment. The Plan denied your request. The Plan says this service is not covered when it is billed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation, low- level laser treatment and extracorporeal shock 
wave treatment provided from December 6, 2021, through January 24, 2022.