Persius/hicric huggingface dataset:
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 IRF services to fully recover 
and regain maximum independence. The Plan denied your request. The Plan says the enrollee does 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
March 7, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
are not supported. 
 
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 80307 is presumptive drug testing. The definition of code 
G0483 is definitive drug testing of 22 or more drug classes.  
 We find that CPT codes 80307 and G0483 are not supported in the medical record. The records provided do 
not include results for the testing at issue. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 80307 and G0483 billed for date of service March 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart System implantable pulse 
generator (0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart System implantable pulse generator. You say that this 
is medically necessary. The Plan denied your request. The Plan says this is considered experimental, 
investigational, and unproven. 
 
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 Optimizer Smart System 
implantable pulse generator. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found cardiac contractility modulation remains 
the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. 
 
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 Optimizer Smart System implantable pulse generator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Optimizer Smart System implantable 
pulse generator (0408T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the office visit (99214) and collection of blood (36415) 
provided on September 11, 2023. 
 
You asked the Plan to pay for  the office visit and collection of blood. You say that the services should be 
covered. 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 which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to pay for falls within the Physician/Practitioner services, including 
doctor's office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1000 deductible which applies to Physician/Practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit and 
collection of blood was received on September 11, 2023. Therefore, we decided that the Plan does not have to 
pay for  the office visit (99214) and collection of blood (36415) provided on September 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Visudyne.  
 
You asked the Plan to pre-approve Visudyne. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not being prescribed for a medically necessary 
indication.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Visudyne. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that Visudyne is not FDA-approved 
for the enrollee's diagnosis of non-proliferative diabetic retinopathy with macular edema. Visudyne (verteporfin 
for injection) therapy is a photo enhancer indicated for the treatment of patients with predominantly classic 
subfoveal choroidal neovascularization due to age-related macular degeneration, pathologic myopia or presumed ocular histoplasmosis. The enrollee is not identified as having any of these conditions. The use of 
Visudyne is not indicated, not supported, and not recommended for the submitted diagnosis of diabetic 
retinopathy with macular edema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Visudyne have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Visudyne.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on June 23, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were informed that 
you did not need to go to the emergency room. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on June 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on August 7, 2023. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the CT scan was done prior to a 
surgical procedure and the Plan should waive 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 $350 
copayment per visit for all other outpatient diagnostic and therapeutic services, including CT scans. 
 
You have been asked to pay $115.10, which is less than the standard copayment for a CT scan. 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 CT scan provided on August 7, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 18, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was no longer on hospice at 
the time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the magnetic resonance imaging (MRI), neck provided 
on June 23, 2023. 
 
You asked the Plan to pay more for the MRI, neck. You say that you would like the payment reviewed because 
it was not for the correct 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copayment for advanced imaging services at an outpatient hospital.  
 
The enrollee has been asked to pay a $199.22, which is less than the standard $295 copayment for the MRI, 
neck. This item/service falls within the advanced imaging services benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to pay more for the magnetic resonance imaging (MRI), neck provided on June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service May 30, 2023. 
 
You asked the Plan to pay for the billed testing. You say that specimens are sent by physicians. The Plan 
denied your request. The Plan says the records do not include a physician order. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there is no order/requisition that documents the testing 
the physician requested. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
May 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are 
necessary for you to get places as there is nobody who can drive you. The Plan denied your request. The Plan 
says you have exhausted your yearly benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3rd level injection. 
 
You asked the Plan to pre-approve 3rd level injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the provider did not provide evidence of unique circumstances for a third 
level with sufficient documentation of medical necessity on appeal. 
 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 3rd level injection. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the LCD limits the number of levels 
injected to 2 per session. The request for additional levels is considered not medically reasonable and 
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 3rd level injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 3rd level injection.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pay for SNF services past the 100-day limit. 
 
You asked the Plan pay for  SNF services.. You say that the enrollee requires the SNF services. The Plan 
denied your request. The Plan says the enrollee has received 100 days of SNF services. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 1, 2023, 
to November 22, 2023. The Plan has covered 100 days of SNF care.  
 
 
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have pay for SNF services past the 100-day limit.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 billed for date of service July 18, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says that the code is 
not separately billable. 
 
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. 
 
We looked at the file and the rules. The claim shows that only the code at issue, G0483, was billed. The Plan 
has not provided documentation that other codes were billed on the date of service at issue. Additionally, the 
Local Coverage Article states that testing for metabolites are not separately billable when billed along with 
code G0483. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for procedure 
code G0483 billed for date of service July 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 kit sensor.  
You asked the Plan to pre-approve the FreeStyle Libre 2 kit sensor. The Plan denied your request. The Plan 
says you do not meet the Medicare criteria for coverage of a CGM. 
 
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 Libre 2 kit sensor. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found coverage criteria require 
that your have low blood glucose sugar or uses insulin for CGM coverage. You have neither and it does not 
appear that you have diabetes mellitus by A1C. Although the CGM may help you, coverage criteria are not 
met. 
 
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 Libre 2 kit sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre 2 kit sensor.
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 the number of hours of physical therapy 
provided in 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewings (D0277) provided on July 26, 2023. 
 
You asked the Plan to pay for vertical bitewings (D0277). You say that are appealing with supporting records. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for vertical 
bitewings (D0277) provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
May 25, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
are not supported. 
 
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 80307 is presumptive drug testing. The definition of code 
G0483 is definitive drug testing of 22 or more drug classes.  
 
 We find that CPT codes 80307 and G0483 are not supported in the medical record. The records provided do 
not include lab results for the testing at issue. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 80307 and G0483 billed for date of service May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injection. 
 
You asked the Plan to pre-approve genicular nerve branch injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this 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 genicular nerve branch injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy. Therefore, the request is deemed 
not medically reasonable and 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 genicular nerve branch injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injection.