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

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
August 19, 2022, through August 23, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital care 
provided from August 19, 2022, through August 23, 2022. Our reviewer says that the acute inpatient 
psychiatric hospital care provided was not medically necessary. Our physician reviewer found that the enrollee 
was admitted for acute inpatient psychiatric hospitalization on August 5, 2023 with Bipolar Disorder. Based 
upon the review of the records provided, it was not expected that this enrollee would improve in a reasonable 
period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory 
or visual hallucinations and was without aggressive behaviors while not showing any acute threats of safety. It 
did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level 
of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or 
homicidal thoughts, auditory or visual hallucinations, or abnormal behaviors. The health plans denial of 
continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental 
health treatment beyond the dates in question as noted above as he was not a danger to himself or others and 
did not have any delusions, or auditory and visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or were for the purpose of a 
diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon the review of 
the records provided, this enrollee does not meet the criteria for coverage of the acute inpatient mental health 
treatment provided beyond the date in question of August 19, 2023 forward and could have been treated in a 
lesser restrictive 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 acute inpatient psychiatric hospital care provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care 
provided from August 19, 2022, through August 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you started 
having chest pains, difficulty breathing and the rescue inhaler did not provide any relief. You also say that you 
were diagnosed with asthma and atrial fibrillation and this had never happened before so you called 911. The 
Plan denied your request. The Plan says these services are not a covered benefit.  
 
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 April 18, 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 the ambulance response and treatment with no 
transport provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), height adjustable receiver for joystick (K0108), controller joystick module Q-
Logic 3, 4 key with color (A9900), and bracket center mount foot plate (A9900). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, height adjustable 
receiver for joystick, controller joystick module Q-Logic 3, 4 key with color, and bracket center mount foot 
plate. You say that you would like the provided documentation to be reviewed for medical necessity. The Plan 
denied your request. The Plan says the requested expandable controller, expandable controller harness and 
electronic connection exceeds the enrollee's need and is not reasonable and necessary. A K0108 joystick mount 
is part of the expandable controller should not be requested separately. The Plan also says the controller 
joystick module Q-Logic 3, 4 key with color and bracket center mount foot plate are unbundled and cannot be 
covered separately. 
 
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 electronic connection, harness, 
expandable controller, height adjustable receiver for joystick, controller joystick module Q-Logic 3, 4 key with 
color, and bracket center mount foot plate. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has 
multiple sclerosis (MS) and 4 out of 5 strength bilaterally in their upper extremities. The enrollee has sufficient 
strength and function in upper extremities to manage standard power drives. Our reviewer found that the 
expandable controller and associated accessories are not medically necessary. Our physician reviewer also 
found that the provided records in this case do not support necessity of the requested bracket center mount foot 
plate (A9900) for the power wheelchair, as two adjustable angle foot plates (K0040) have already been 
approved for the wheelchair and the bracket center mount foot plate (A9900) appears to be duplicative. 
 
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 electronic connection, harness, expandable controller, height adjustable 
receiver for joystick, controller joystick module Q-Logic 3, 4 key with color, and bracket center mount foot 
plate have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic 
connection (E2311), harness (E2313), expandable controller (E2377), height adjustable receiver for joystick 
(K0108), controller joystick module Q-Logic 3, 4 key with color (A9900), and bracket center mount foot plate 
(A9900).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A6402 for date of service January 25, 2022.  

You asked the Plan to pay for code A6402. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the number of units billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity. 
 
We find that 60 units of CPT code A6402 are not supported in the medical record. Review of the file shows 
that the submitted medical records indicate that gauze was delivered; however, the records do not support the 
number of units billed. Without this documentation, this code is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of code A6402 have not been met. Therefore, we 
decided that the Plan does not have to pay for code A6402 for date of service January 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix. 
 
You asked the Plan to pre-approve Granix. You say that Granix is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the use of Granix. 
 
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 Granix. Our reviewer says the service is 
not medically necessary. Our physician reviewer says that the requested use of Granix is not Food and Drug 
Administration-approved for the enrollee's diagnosis and is not supported by one of the major drug compendia 
or by a CMS-approved medical journal. The use of Granix in this case does not meet Medicare criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left shoulder orthosis (L3960) provided on April 20, 
2023. 
 
You asked the Plan to pay for the left shoulder orthosis. You say that the item should be covered. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain or relevant medical records which support medical necessity for the supplies provided in this case. There was no documentation or complaints of pain in these regions, functional 
limitations, or imaging of the left shoulder. There is no indication a shoulder brace was discussed or ordered.  
Therefore, we decided that the Plan does not have to pay for the left shoulder orthosis (L3960) provided on 
April 20, 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 intensive inpatient rehabilitation 
with daily physician management, 24-hour specialized rehab nursing, and intensive therapies to optimize 
mobility and strengthening while ensuring the restoration of functional status for a safe and sustainable 
discharge. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
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 the enrollees 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) kit. You asked the Plan to pre-approve a Dexcom G6 CGM kit. You say that the enrollee should be qualified for 
the glucose monitor. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the CGM kit. 
 
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 enrollee 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 G6 CGM kit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G6 continuous glucose monitor (CGM) kit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the records did not indicate a suspicion 
for either let alone both AD and FTD. In this setting/context the request would not satisfy the base 
requirements for coverage of this service. Furthermore, the NCD limits performance of a PET/CT to one scan. 
In this case the member was noted to have previously undergone PET/CT in the past (and it was 
unremarkable). In such a setting the requirements of the NCD would not be 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on April 23, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that there was a shorter wait time to schedule an 
appointment at Costco. You say your share of the cost at Costco was significantly less. The Plan denied your 
request. The Plan says the provider is out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by a network provider or vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider is out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on April 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D4266) and a bone replacement 
graft for ridge preservation (D7953) provided on May 4, 2023. 
 
You asked the Plan to pay for D4266 and D7953. You say that you needed this dental work. The Plan denied 
your request. The Plan says these services have been correctly denied. 
 
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 a guided 
tissue regeneration (D4266) and a bone replacement graft for ridge preservation (D7953) provided on May 4, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting for reconsideration for payment. 
The Plan denied your request. The Plan says the services are not authorized because Puget Sound Chiropractic 
PLLC is a non-network provider who does not work with the enrollee's health Plan. 
 
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 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 office visit provided on February 17, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 00142 provided on March 30, 2022. 
 
You asked the Plan to pay for procedure code 00142. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 00142 based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for procedure code 00142 provided on March 30, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service March 15, 2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a covered benefit. The Plan denied 
your request. The Plan says the test is not supported. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met.  The file shows that a DecisionDX-SCC test was provided. We looked at the file and Medicare rules. After 
technical assessment by the MolDX program, this test is not covered based on clinical validity. 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 the lab testing billed for date of service March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service April 21, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 The file shows that a urinary tract infection panel was provided. We looked at the file and the rules. The panel 
testing was not billed with a single code as required. 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 the panel testing billed for date of service April 21, 2023.