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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on June 
15, 2023, to June 29, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not informed 
this was a hospital. 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 $109 
copayment for inpatient hospital care. 
 
You have been asked to pay a $109 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care 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. You have been asked to pay a total of $654 for the inpatient hospital stay ($109 copayment 
x 6 days = $654). Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided on June 15, 2023, to June 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on May 4, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that the medical records support the billing of 
procedure code 99284. The Plan denied your request. The Plan says the medical records do not support the 
billing of procedure code 99284. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
We asked our coder 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 procedure code 99284. Our reviewer says that the medical records do not support the billing of procedure code 99284. Our reviewer found based on the documentation 
provided, the enrollee was evaluated in the emergency department for a painful, red eye. An appropriate history 
and physical were documented. The medical decision making was not of moderate complexity. As such, the 
billing of CPT code 99284 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 provided on May 4, 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 needs inpatient rehabilitation to regain 
mobility so they can perform daily living activities. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, but skilled therapies at a skilled nursing facility (SNF) may be approved 
upon request.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyaluronan. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our reviewer says that 
the criteria for coverage of hyaluronan have not been met. Our physician reviewer found that the Plan requires 
a trial of Synvisc, Synvisc-One or Euflexxa before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plan's required drugs would likely be less effective or likely have adverse effects for the 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyaluronan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient instrumentation removal and anterior cervical 
discectomy and fusion (ACDF) procedure. 
 
You asked the Plan to pre-approve inpatient instrumentation removal and anterior cervical discectomy and 
fusion (ACDF) procedure. You say that this is medically necessary. The Plan denied your request. The Plan 
says detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive 
conservative care measures is not evident. The proposed procedure is a re-do with a high risk of complications, 
and therefore, conservative treatment before re-operation is indicated. 
 
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 inpatient instrumentation removal and 
anterior cervical discectomy and fusion (ACDF) procedure. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the records in 
this case do not document recent trial and failure of non-surgical treatments for the patient's neck pain. 
Provided records do not document the patient has disabling neurologic deficits as would be required by the 
standard of care for proceeding to surgery as opposed to a trial of non-surgical treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient instrumentation removal and anterior cervical discectomy and fusion 
(ACDF) procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
inpatient instrumentation removal and anterior cervical discectomy and fusion (ACDF) procedure.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve skin substitute. 
 
You asked the Plan to pre-approve skin substitute. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that the enrollee does not meet the requirements for 
approval. 
 
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 skin substitute. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that all first line therapies have failed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute have been met. Therefore, we decided that the Plan has to pre-
approve skin substitute.  
 
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 patient lift, hydraulic or mechanical, includes any seat, 
sling, strap(s) or pad(s) (E0630). 
 
You asked the Plan to pre-approve a patient lift. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a patient lift is covered if transfer between bed and a 
chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined. 
 
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 patient lift. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
you require a mechanical lift for transfers or that you would be bed bound without a mechanical lift. You are 
able to ambulate household distances with assistance. 
 
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 patient lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) (E0630).
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 is stable and suitable for transfer to an 
IRF. You also say that skilled nursing is not an appropriate safe level of care at this time as they will need more 
frequent physician visits with intensive physical therapy and occupational therapy with frequent monitoring 
and interventions. The Plan denied your request. The Plan says admission to the IRF 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne (F1CDx) comprehensive genomic 
profiling test (81479) provided on April 11, 2023. 
 
You asked the Plan to pay for the F1CDx testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says there is no documentation regarding the stage of the enrollee's cancer. 
 
The Plan follows Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
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 F1CDx testing. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the enrollee has newly diagnosed 
colon cancer. It is unclear what stage the enrollee has from the provided clinical documentation. Thus, the 
criteria for coverage are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the F1CDx testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the FoundationOne (F1CDx) comprehensive genomic profiling test (81479) provided on 
April 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
02, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient hospital services/outpatient surgery. 
 
You have been asked to pay a $250 copayment for an outpatient surgery. This item/service falls within the 
outpatient hospital services/outpatient surgery 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 outpatient surgery provided on August 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has COPD and was recently hospitalized after a syncopal episode. Arterial blood gas was 
consistent with chronic carbon dioxide (CO2) retention. The enrollee improved with BiPAP in the 
hospital. There is no diagnosis of thoracic restrictive disease or neuromuscular disease. The enrollee may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. The 
records do not show that this treatment has been tried as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multiaxial ankle with swing phase (L5968) and flex-
walk system (L5981). 
 
You asked the Plan to pre-approve ankle unit and flex-walk system. You say that the enrollee's functional level 
justified the need for these components. The Plan denied your request. The Plan says the requested foot 
exceeds the enrollee's medical needs. 
 
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 ankle unit and flex-walk system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the supporting documentation does not show that the enrollee had the prior 
ability or future potential for variable cadence which is necessary for K3 functional level classification. The 
Blatchford Echelon is categorized with L5981 and L5968. L5968 is the separate hydraulic ankle unit feature 
and it does not describe the complete prosthetic foot system. L5968 may used in combination with the L5981 
along with other prosthetic foot L-codes. It is commonly used in combination of K2 and K3 level feet on the 
market that feature a hydraulic ankle. For this reason, the foot does not meet criteria in its entirety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ankle unit and flex-walk system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a multiaxial ankle with swing phase (L5968) and flex-walk system 
(L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided 
from May 28, 2023, to May 31, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump (E0218) provided from May 28, 2023, to May 
31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression Garment system 
(K1033, K1024). 
 
You asked the Plan to pre-approve a Koya Dayspring Active Compression Garment system. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 a Koya Dayspring Active Compression 
Garment system. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the requested device has not been shown to be 
superior to other standard treatments for the medical condition. The studies do not indicate the Koya Dayspring Active Compression Garment system improves an individuals function or general health compared to standard 
treatment. The requested device 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 a Koya Dayspring Active Compression Garment system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring Active Compression 
Garment system (K1033, K1024).