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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 28, 2021, 
through July 30, 2021, and billed with diagnosis code A41.2. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.2 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.2. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.2-sepsis due to 
unspecified staphylococcus. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
primary diagnosis of A41.2-sepsis due to unspecified staphylococcus. Our physician reviewer found the 
member met an inpatient level of care per multiple condition management (MCG) for sepsis and other febrile 
Illness, without focal infection, evidenced by bacteremia that required intravenous ceftriaxone (IV) antibiotics 
and close monitoring of the members complex medial conditions on an inpatient basis. Therefore, diagnosis 
code A41.2-sepsis due to unspecified staphylococcus is the appropriate primary diagnosis. 
  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 28, 2021, through July 30, 2021, and billed with diagnosis code 
A41.2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services 
 You asked the Plan to pre-approve home health services. You say that you had surgery, and you need the 
proper care in your home. The Plan denied your request. The Plan says the previous provider has provided all 
the medical necessity management that was needed, and you are no longer homebound; therefore, the services 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled nursing needs. While the enrollee reportedly has an ostomy, this 
ostomy is 6 months old. There is no documentation of current infection or issues necessitating home health 
skilled nursing care for ostomy care. The enrollee appears able to attend medical appointments, calling into 
question his homebound status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is 
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 Intracept procedure. Our reviewer 
says that the requested the Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found the Intracept procedure is considered an experimental therapy at this time. There 
are multiple other pain generators demonstrated on the magnetic resonance imaging. 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 the Intracept procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI of the lower extremity provided on October 25, 
2022, and digital breast tomosynthesis and a screening mammogram provided on November 29, 2022, by an 
OON provider. 
 
You asked the Plan to pay for an MRI, breast tomosynthesis, and a mammogram. You say that you are 
requesting reconsideration of the denied claims. The Plan denied your request. The Plan says that these services 
are 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 Plan contract also says that the enrollees POS benefit does 
not apply to out-of-network radiology services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an MRI of the lower extremity provided on 
October 25, 2022, and digital breast tomosynthesis and a screening mammogram provided on November 29, 
2022, by an OON provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo (nivolumab) 1MG injection (J9299). 
 
You asked the Plan to pre-approve the drug. You say that the medication is necessary. The Plan denied your 
request. The Plan says that based on the lack of an indication for using Opdivo for squamous cell carcinoma of 
the bladder, the off-label denial is upheld under Part C. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the drug. Our physician reviewer found 
the requested use of the drug is FDA-approved for the enrollees diagnosis because it is supported by National 
Comprehensive Cancer Network (NCCN) Guidelines for adjuvant treatment if T3N0 disease. The 
documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 
for this enrollee. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Opdivo (nivolumab) 1MG injection (J9299).  
 
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 Kit Sensor. 
 
You asked the Plan to pre-approve the FreeStyle Kit Sensor. You say that the enrollee checks his blood sugar 4 
times a day. The Plan denied your request. The Plan says the enrollee does not require insulin three or more 
times daily. 
 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 the enrollee does not use insulin 
with at least three daily injections. 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.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the replacement of a permanent spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the replacement of a SCS. You say that the service is medically necessary. 
The Plan denied your request. The Plan says that the enrollee has not had another recent psychological 
evaluation. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 replacement of a SCS. Our reviewer 
says that the requested service is considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no Medicare criteria that requires ongoing periodic psychological evaluation when 
managing/changing a SCS generator. 
 
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 replacement of a SCS have been met. Therefore, we decided that the Plan 
has to pre-approve the replacement of a permanent spinal cord stimulator (SCS).  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live at home alone and need assistance with your 
daily activities. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
your needs can be met at an alternate level of care. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
for the denial of an IRF admission. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The clinical 
documentation shows that the enrollee requires physical and occupational therapy but not an intensive 
rehabilitation regimen. 
 
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are blind and needs assistance with daily living 
activities due to having a stroke 3 years ago. The Plan denied your request. The Plan says a SNF admission is 
not medically necessary, and your needs can be met in an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure (64628). 
 
You asked the Plan to pre-approve an intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 an intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the cause of back pain in this patient is unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the right Shoulder Arthroscopy with Rotator Cuff 
Repair, Biceps Tenodesis vs. Tenotomy, Subacromial Decompression, Debridement of Degenerative Labrum 
vs. Extensive Debridement (29823, 29826, 29827). 
 
You asked the Plan to pre-approve the right Shoulder Arthroscopy with Rotator Cuff Repair, Biceps Tenodesis 
vs. Tenotomy, Subacromial Decompression, Debridement of Degenerative Labrum vs. Extensive Debridement. 
You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 
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 right Shoulder Arthroscopy with 
Rotator Cuff Repair, Biceps Tenodesis vs. Tenotomy, Subacromial Decompression, Debridement of Degenerative Labrum vs. Extensive Debridement. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found detailed 
documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative 
care measures is not evident. Additionally, the provided Magnetic Resonance Imaging (MRI) did not 
corroborate pathology to support the requested procedures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 right Shoulder Arthroscopy with Rotator Cuff Repair, Biceps Tenodesis vs. 
Tenotomy, Subacromial Decompression, Debridement of Degenerative Labrum vs. Extensive Debridement 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the right Shoulder 
Arthroscopy with Rotator Cuff Repair, Biceps Tenodesis vs. Tenotomy, Subacromial Decompression, 
Debridement of Degenerative Labrum vs. Extensive Debridement (29823, 29826, 29827).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued home oxygen (E1390). 
 You asked the Plan to pre-approve the continued home oxygen. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 continued home oxygen Our 
reviewer says that the item is not medically necessary. Our physician reviewer found that there is no 
documentation that the patient has nocturnal hypoxemia or that the patient still needs and is using oxygen. 
 
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 continued home oxygen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued home oxygen (E1390).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductibles for the surgical excision provided on 
November 18, 2022, and the lesion removal provided on December 13, 2022. 
 
You asked the Plan to waive the deductibles for the excision and lesion removal. You say that you were sent to 
the dermatologist by the podiatrist and received a bill from both offices. 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 $400 deductible which applies to outpatient hospital services. Your 
contract with the Plan also says that there is a $0 copayment once the deductible has been met for outpatient 
hospital services. 
 
You have been asked to pay $123.52 towards your deductible for the surgical excision. You have also been 
asked to pay $108.59 towards your deductible for the lesion removal. You have been asked to pay a total of 
$232.11 ($123.52 + $108.59 = $232.11). The items or services you asked the Plan to waive the deductibles for 
fall within the outpatient hospital services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $400 deductible which applies to outpatient hospital services. This cost 
sharing is a contractual obligation that had not been met at the time the excision and lesion removal was 
received on November 18, 2022, and December 13, 2022. Therefore, we decided that the Plan does not have to 
waive the deductibles for the surgical excision provided on November 18, 2022, and the lesion removal 
provided on December 13, 2022.