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

 
We decided that the Plan does not have to pre-approve laser cataract surgery with light adjustable option and 
multifocal intraocular lens (IOL). 
 
You asked the Plan to pre-approve laser cataract surgery with light adjustable option and deluxe IOL. You say 
that it is your understanding that this is necessary. The Plan denied your request. The Plan says these services 
are either not medically necessary or not covered by Medicare. 
 
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 laser cataract surgery with light 
adjustable option and deluxe IOL. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is no necessity in 
undergoing bladeless, computed controlled laser cataract surgery instead of the conventional techniques. There 
is no necessity in requiring implantation of a presbyopia-correcting (P-C) intraocular lens (IOL) or 
astigmatism-correcting (A-C) IOL instead of a conventional IOL. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laser cataract surgery with light adjustable option and deluxe IOL have not been 
met. Therefore, we decided that the Plan does not have to pre-approve laser cataract surgery with light 
adjustable option and multifocal intraocular lens (IOL).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 07, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 October 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care billed for dates of service 
August 10, 2022, to August 13, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee had worsening weakness and 
frequent falls. The Plan denied your request. The Plan says a lower level of care, such as observation, was more 
appropriate.  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 inpatient care. Our physician reviewer 
found that the enrollee presented to the emergency department with worsening weakness, frequent falls, and a 
recent hospitalization for a stroke. Physical therapy evaluated the enrollee and recommended subacute rehab 
facility placement for ongoing supervised physical and occupational therapy. The enrollee appeared to be 
hemodynamically stable on evaluation and was appropriate for observation status until placement. There was 
no expectation that the enrollee would require hospitalization that would likely cross 2 midnights.  
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the acute inpatient hospital care billed for dates of service August 10, 2022, to August 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that the enrollee has tried a sample and has 
already improved with control. You also say that without this the enrollee might have to restart insulin or more 
expensive medications. The Plan denied your request. The Plan says we reviewed the medical records and did 
not see any insulin use or any records documenting low blood glucose levels. 
 
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 Dexcom G7 sensor. Our reviewer 
says that the Dexcom G7 sensor is not medically necessary. Our physician reviewer found although the CGM 
might help the enrollee adjust diet, etc., criteria for the CGM are not met. Namely insulin is not being used and 
no low blood glucose sugar is noted. 
 
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 Dexcom G7 sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G7 sensor.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve zoledronic acid. 
 
You asked the Plan to pre-approve zoledronic acid. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this drug is not medically necessary. 
 
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 zoledronic acid. Our reviewer says that 
zoledronic acid is medically reasonable and necessary. Our physician reviewer found that zoledronic acid is 
Food and Drug Administration (FDA) approved for the prevention of osteoporosis in postmenopausal women. 
The Medicare-approved drug compendia and the FDA approved product information from the drug 
manufacturer do not limit this indication to patients with a 10-year probability of a hip fracture of 3% or more 
or a 10-year probability of any major osteoporotic fracture of 20% or more.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of zoledronic acid have been met. Therefore, we decided that the Plan has to pre-
approve zoledronic acid.  
 
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 pay for a chest x-ray provided on August 19, 2022. 
 
You asked the Plan to pay for a chest x-ray. You say that this was medically necessary and should be covered. 
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 a chest x-ray provided 
on August 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis provided by an out-of-network provider on 
January 5, 2023. 
 You asked the Plan to pay for the orthosis. You say that the services provided were based on the physicians 
order. The Plan denied your request. The Plan says the Medicare guidelines were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers may not contact a beneficiary by 
telephone when supplying a Medicare-covered item unless the individual has given written permission to the 
supplier to contact them by telephone, the supplier has furnished a Medicare-covered item to the individual and 
is trying to coordinate the delivery, or if there is evidence that the supplier has furnished at least one covered 
item to the individual during a 15-month period preceding the date on which the supplier makes contact. 
 
We looked at the file and Medicare rules. We found that the physician assistant who contacted the enrollee by 
phone to evaluate and order the items in dispute, worked on behalf of the durable medical equipment provider. 
The documentation provided did not demonstrate that the enrollee gave written permission for this provider to 
contact them by phone. The documentation provided did not demonstrate that the supplier has furnished a 
Medicare-covered item to the individual and was trying to coordinate the delivery. The documentation 
provided did not demonstrate that the supplier had furnished any other covered items to the enrollee within the 
15-months preceding the date on which the supplier made contact. Based on this information, we decided that 
Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the orthosis provided by an out-of-network provider on January 5, 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 inpatient acute rehabilitation in 
effort to facilitate increased independence and return home to community with improved quality of life. The 
Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an 
Inpatient Rehabilitation 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 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. 
 
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 laboratory testing provided on February 24, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. 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 laboratory testing 
provided on February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous positive airway pressure (CPAP) device (E0601) 
provided on December 27, 2022, through January 27, 2023. 
 
You asked the Plan to pay for the CPAP device. You say that the item should be covered. The Plan denied your 
request. The Plan says that prior authorization was not obtained. 
 
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 hasnt provided a valid denial reasoning or any records to support the 
denial. The Plans EOC indicates you do not need prior authorization to obtain services.  Therefore, we decided 
that the Plan has to pay for the continuous positive airway pressure (CPAP) device (E0601) provided on 
December 27, 2022, through January 27, 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: 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 would like to be admitted to 
the requested facility to regain strength. The Plan denied your request. The Plan says the LTACH services 
requested 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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. 
 
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: 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 you are requesting a fast appeal as the 
enrollee currently meets acute LTACH admission criteria. The Plan denied your request. The Plan says the 
LTACH services requested 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 21, 2022, billed 
with procedure code 70553. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10- CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate for a provider to 
report an unspecified diagnosis and a left or right diagnosis code. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with diagnosis code 
C78.00 (Secondary malignant neoplasm of unspecified lung) and diagnosis code C78.01 (Secondary malignant 
neoplasm of right lung) which are inappropriately billed together. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on December 21, 2022, billed with procedure code 70553.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy (PT) services provided from March 31, 2022, to May 
4, 2022. 
 
You asked the Plan to pay for the therapy services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that these services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the therapy services. Our reviewer says that 
these services meet criteria for payment. Our physician reviewer found the enrollee underwent a left-side hip 
arthroplasty on March 29, 2023 and was discharged home. The initial physical therapy evaluation was 
performed on March 31, 2023 and the enrollee was noted to have limited mobility as well as ability to transfer. 
The enrollee was noted to have decreased motor strength in the lower extremities after surgery. The enrollee 
required physical therapy to improve mobility and function and maximize the enrollee's independence as well 
as improve strength. The enrollee's level of mobility improved with physical therapy after the initial evaluation. 
Therefore, these visits were medically 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 therapy services have been met. Therefore, we decided that the Plan has to 
pay for physical therapy (PT) services provided from March 31, 2022, to 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 27, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardiology reading provided 
on February 25, 2023. 
 
You asked the Plan to waive the copayment for an in-network cardiology reading. You say that the providers 
who read your cardiology monitor didnt even call you with results. No one told you that there would be a 
copay. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for an in-network cardiology reading. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 in-network cardiology reading provided on February 25, 2023.