Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiographic monitoring provided on June 22, 2023. 
 
You asked the Plan to pay for electrocardiographic monitoring. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for approval. 
 
The Plan follows Medicare rules. Medicare rules say that the use of external electrocardiographic recording for 
greater than 48 hours and up to 7 days or for greater than 7 days up to 15 days by continuous rhythm recording 
and storage, may be considered medically necessary in patients treated for reasons listed in the diagnosis list to 
monitor for asymptomatic episodes in order to evaluate treatment response. The use of external 
electrocardiographic event monitors for greater than 48 hours and up to 7 days or for greater than 7 days up to 15 days that are either patient-activated or auto-activated may be considered medically necessary as a 
diagnostic alternative to Holter monitoring in patients who experience infrequent symptoms (less frequently 
than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope). 
(Refer to current CPT codebook) 
 
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 electrocardiographic monitoring. Our 
reviewer says that the service is not medically necessary.  
 
Our physician reviewer found an event monitor was requested and approved. This is a second request for 
electrocardiographic monitoring (event monitor) 2 weeks later. However, the provided documentation does not 
clearly explain the clinical reasoning for repeating the monitoring for you. It was not clearly described in the 
provided documentation whether this request was made in error as it was already approved, or if it was meant 
to be repeated. The results of the first event monitoring were not provided if they were completed. Therefore, 
the coverage criteria will be considered not met at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electrocardiographic monitoring have not been met. Therefore, we decided that 
the Plan does not have to pay for electrocardiographic monitoring provided on June 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on July 13, 2023. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you should not 
have to pay for the service. 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 $125 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $125 copayment for computed tomography (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 computed tomography (CT) scan provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on June 19, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the diabetic supplies 
provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on June 19, 
2023, to June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told this would 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 by an OON provider on June 19, 2023, to June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telephone evaluation provided on 
August 03, 2023. 
 
You asked the Plan to waive the copayment for the telephone evaluation. You say that you were just given 
laboratory results, you did not have an appointment. 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 $15 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for the telephone evaluation. This item/service falls within the in-network 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 the telephone evaluation provided on August 03, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for denosumab injection provided on January 
17, 2022. 
 
You asked the Plan to reduce the coinsurance for denosumab injection. You say that you should not be billed 
for additional money when you paid the billed amount in 2022. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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. The total you owe is $270.59 ($1,352.94 allowed amount x 20% = $270.59). 
Therefore, we decided that the Plan does not have to reduce the coinsurance for denosumab injection provided 
on January 17, 2022.
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 medical records provided support the need for 
the requested inpatient rehabilitation facility admission. The Plan denied your request. The Plan says based on 
the available information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not 
meet the Medicare rules.  
 
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 enrollee does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met at 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator with a case and 
accessories. 
 
You asked the Plan to pre-approve a portable oxygen concentrator with a case and accessories. You say that 
you need the portable oxygen because you had shortness of breath while in the grocery store. The Plan denied 
your request. The Plan says the requested portable oxygen concentrator is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. 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 a portable oxygen concentrator with a 
case and accessories Our reviewer says that a portable oxygen concentrator with a case and accessories is not 
medically necessary. Our physician reviewer found that the documentation does state that you have three 
portable oxygen tanks and home oxygen therapy. Also, you have been supplied and if, for some reason those 
tanks are too heavy or limiting your mobility, then a lightweight portable oxygen tank would be indicated. 
However, there is no documentation that states you cannot carry or preform activities of daily living with your 
current tanks. Also, there is no evidence showing you are limited in mobility or capacity to carry the tanks 
provided. Therefore, you do not meet the criteria of a lightweight portable oxygen tank. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator with a case and accessories have not been met.  
Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator with a case 
and accessories.
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 requested IRF services are necessary because you 
live alone and are a fall risk. You also say you need physical therapy to regain the ability to walk. The Plan 
denied your request. The Plan says the notes do not show that your care specifically requires the involvement 
of a doctor in the field of Rehabilitation Medicine; the notes do not show that you have complex care needs that 
require a coordinated team approach; the notes do not show that you must have an intensive therapy program (3 
hours a day, at least 5 days a week) in order to improve self-care functioning.  
 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 can be provided in 
a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You require treatment by multiple therapies, including physical therapy and occupational 
therapy, but this can be provided in a lower level of care. There is documentation that there is a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF, but the services required can be provided at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital inpatient visit and the discharge day 
management services provided on August 09, 2022, to August 13, 2022. 
 
You asked the Plan to pay for the subsequent hospital inpatient visit and the discharge day management 
services. You say that you are requesting reconsideration of the denied claim. The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent hospital 
inpatient visit and the discharge day management services provided on August 09, 2022, to August 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you need this to recover. The 
Plan denied your request. The Plan says this device is excluded from Medicare coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the left total hip arthroplasty to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the left total hip arthroplasty. You say that the requested facility and 
provider are INN for the enrollee's plan.  The Plan denied your request. The Plan says the enrollee does not 
have out-of-network benefits. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The provider at issue in this case is not a network provider with the Plan. 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 left total hip arthroplasty. Our reviewer says that the service is not 
medically necessary Our physician reviewer found the enrollee has hip degenerative joint disease. The surgery 
can be safely performed in-plan. There is no need for an out-of-network referral. 
 
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 left total hip arthroplasty have not been met.  
 
The Plan has network providers available who can provide the left total hip arthroplasty. We found no 
exception that would require the Plan to pre-approve the left total hip arthroplasty. Therefore, we decided that 
the Plan does not have to pre-approve the left total hip arthroplasty to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cryoablation of a left renal mass. 
 
You asked the Plan to pre-approve cryoablation of a left renal mass. You say that cryoablation of a left renal 
mass has been recommended by three doctors and is medically necessary. The Plan denied your request. The 
Plan says that cryoablation of a left renal mass is not medically necessary. The Plan says there is no 
documentation to support standard surgical approach is likely to substantially worsen kidney function.  
 
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 cryoablation of a left renal mass. Our 
reviewer says that the requested cryoablation of a left renal mass is considered medically reasonable and 
necessary in this case. Our physician reviewer found that you will benefit greatly from the minimally invasive 
procedure versus having an invasive procedure. Risk and recovery from procedure is significantly lower with 
the percutaneous procedure. It is in your best interest to get this procedure to preserve remaining renal function 
and a reduced stay in hospital with increased level of function anticipated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cryoablation of a left renal mass have been met. Therefore, we decided that the 
Plan has to pre-approve cryoablation of a left renal mass.  
 
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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says 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 Plan. 
Given there are offered alternatives, LTACH is not medically necessary. 
 
 
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 admission to an LTACH is not 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you are currently in the process of 
credentialing as an in-network provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan and the enrollee can be treated within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.