Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan of the heart (75571) provided on 
May 18, 2023. 
 
You asked the Plan to pay for CT scan of the heart. You say that the services were provided during a 
covered/authorized observation care visit, and you did not get to choose which cardiologist would perform the 
urgently needed service in dispute. The Plan denied your request. The Plan says that this provider is out-of-
network, and the service was not authorized. 
 
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. We find that the Plan provided us with no medical records. We cannot evaluate 
whether the services in dispute were provided in an urgent/emergent situation. We cannot determine who 
referred you for this CT scan, and whether that provider/facility was participating with the Plan or had an active 
authorization to treat you. We have no documentation regarding the authorization that was issued for this 
facility, that you claim covered the services provided during an observation stay. Without all of this necessary 
information, the Plan has not substantiated their denial reason. Therefore, we decided that the Plan has to pay 
for a computed tomography (CT) scan of the heart (75571) provided on May 18, 2023.  
 
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 a Dexcom G7 sensor (A4239).  
You asked the Plan to pre-approve a Dexcom G7 sensor. You say that the patient needs the receiver to manage 
their type 2 diabetes. The Plan denied your request. The Plan says the information does not indicate that the 
reasonable and necessary criteria have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the patient does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G7 sensor (A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided on September 19, 2023. 
 
You asked the Plan to pay for debridement services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement services 
provided on September 19, 2023.
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 meets all applicable Medicare criteria 
for admission to an acute rehabilitation unit. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in an IRF.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman Interspinous device. 
 
You asked the Plan to pre-approve the Minuteman Interspinous device. You say that the enrollee has suffered 
from persistent radicular and back pain intermittent neurogenic claudication for more than six months. The 
Plan denied your request. The Plan says the Minuteman Interspinous device 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 Minuteman Interspinous device. 
Our reviewer says that the Minuteman Interspinous device is not medically necessary. Our physician reviewer 
found that the Minuteman device is considered experimental, and more research is 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 the Minuteman Interspinous device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Minuteman Interspinous device.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 2, 2023, to 
August 3, 2023, by an out-of-network provider. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says that the enrollee's care needs could have been provided 
at an observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found there was a clear expectation that the enrollee's care would span two midnights at the 
time of hospitalization. The enrollee had a head strike, neurological changes, and several other medical issues 
that necessitated admission. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from August 2, 2023, to August 3, 2023, by an 
out-of-network provider.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diagnostic radiology procedure (73030) 
and surgery (20606), provided on February 28, 2023, through April 28, 2023. 
 
You asked the Plan to waive the cost share for the diagnostic radiology service and surgery. You say that the 
cost share is wrong. 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 $1000 deductible in which the diagnostic radiology service and 
surgery apply and a 45% coinsurance after the deductible which applies to the surgery.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible in 
which the diagnostic radiology service and surgery apply and a 45% coinsurance after the deductible which 
applies to the surgery. This cost sharing is a contractual obligation that had not been met at the time the 
diagnostic radiology service and surgery was received on February 28, 2023, to April 28, 2023. Therefore, we 
decided that the Plan does not have to waive the cost share for the diagnostic radiology procedure (73030) and 
surgery (20606), provided on February 28, 2023, through April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC). 
 
You asked the Plan to pre-approve a power wheelchair. You say that  The Plan denied your request. The Plan 
says a home assessment was not provided. 
 
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 a power wheelchair have been met. 
Specifically, there was no indication that a home assessment has been performed. The record shows that the 
Plan made multiple attempts to obtain this information with no success. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (PWC).
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 approval for admission to an IRF. The Plan 
denied your request. The Plan says you do not meet the requirements for admission to an IRF.  
 
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 complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable, and there are no complex nursing or rehabilitation needs. Medically necessary services can be 
provided in 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on August 17, 2022. 
 
You asked the Plan to pay for the telehealth services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telehealth services 
provided on August 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram provided on 
September 13, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram. You say that the extra $10 is not 
anywhere you can find. Seems to just be an arbitrary 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the electrocardiogram. This item/service falls 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 the electrocardiogram provided on September 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each nebulizer provided on January 08, 
2023, to March 08, 2023. 
 
You asked the Plan to waive the coinsurance for each nebulizer. You say that you purchased the nebulizer 
outright and do not understand why you are being bill for it now. 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% 
coinsurance for In-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each nebulizer. This item/service falls within the In-network 
durable medical equipment and related 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. You have been asked to pay $2.13 which is 20% coinsurance of 
the allowed amount for each nebulizer ($10.66 x 20%= $2.13). 
The total you owe is $6.39 ($2.13 coinsurance x 3 nebulizers = $6.39). Therefore, we decided that the Plan 
does not have to waive the coinsurance for each nebulizer provided on January 08, 2023, to March 08, 2023.
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 requires the level of care provided in an 
IRF to address their medical and functional needs and maximize their level of independence. The Plan denied 
your request. The Plan says the enrollee does not meet the medical necessity severity or intensity criteria for an 
IRF admission.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. Medically necessary 
services can be provided in 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 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 medical records provided support the 
need for care in an LTACH. The Plan denied your request. The Plan says services can be provided in a skilled 
nursing facility (SNF). 
 
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 the enrollee is a 71-year-old male with chronic obstructive pulmonary disease 
(COPD) on 3 L of supplemental oxygen at home who was admitted for COPD exacerbation. He is receiving 7L 
of supplemental oxygen currently. He does not have complex wound care needs. He does not meet LTACH admission criteria and is receiving appropriate care in his current 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 24, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle kit sensor. 
 
You asked the Plan to pre-approve the FreeStyle kit sensor. You say that the medical records provided support 
the need for the requested CGM. The Plan denied your request. The Plan says Medicare Guidance says a CGM 
is covered under Medicare only if a member with diabetes is on insulin or has documentation of very low blood 
sugars that has occurred several times. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle kit sensor. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as identified by Medicare rules. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 FreeStyle kit sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle kit sensor.