Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that this is a medical necessity. The Plan 
denied your request. The Plan says the notes from the provider do not show that you use an insulin pump or 
being considered for an insulin pump. 
 
 
 
 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist visit provided on January 16, 
2023.   
 
You asked the Plan to waive the deductible for the specialist visit. You say that you do not agree with the cost 
sharing. 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 specialist visits. 
 
You have been asked to pay a $94.41 deductible for the specialist visit. The item or service you asked the Plan 
to waive the deductible for falls within the physician/practitioner services, including doctors office visits 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to physician/practitioner services, including doctors office visits. This cost sharing is 
a contractual obligation that had not been met at the time the specialist visit was provided on January 16, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the specialist visit provided on 
January 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 15, 2022, 
to November 18, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
billed diagnosis codes were valid. The Plan denied your request. The Plan says the billed principal diagnosis of 
A41.89 (other specified sepsis), and secondary diagnosis R65.20 (severe sepsis without septic shock) were not 
supported by the medical record. The principal diagnosis should have been J15.9 (unspecified bacterial 
pneumonia). Removal of these two diagnoses resulted in a lower DRG being paid. 
 
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 a principal diagnosis of A41.89 (other specified 
sepsis), and a secondary diagnosis of R65.20 (severe sepsis without septic shock). 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 billed principal diagnosis of A41.89 (other specified sepsis), and secondary diagnosis 
R65.20 (severe sepsis without septic shock) are not supported by the medical record. Our physician reviewer 
found the member is a 68-year-old male with a past medical history including hypertension who presented to 
the hospital with increased shortness of breath and cough. He was diagnosed and treated for pneumonia. At the 
time of admission, the member's symptoms were improved, and he was afebrile. The laboratory studies were 
not consistent with sepsis. There was no evidence of life-threatening organ dysfunction due to dysregulated 
host response to an infection or persistent hemodynamic instability. In this case, the documentation does not 
consistently and completely support the assigned principal and secondary diagnoses codes with DRG. The 
replacement of DRG is upheld as it is supported by the medical documentation.  
 
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 November 15, 2022, to November 18, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power operated vehicle (K0812). 
 
  You asked the Plan to pre-approve a replacement power operated vehicle. You say that the one you have will 
not last, and it is unsafe. You also say that you would prefer another one because above the ground is higher 
up, and you need big tires so it will not hit the ground. The Plan denied your request. The Plan says the 
requested power operated vehicle replacement is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for DME that is reasonable and 
necessary for treatment of an illness or injury, or to improve the functioning of a malformed body part. 
 
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 replacement power operated vehicle. 
Our reviewer says that a replacement power operated vehicle is not medically reasonable and necessary for 
you. Our physician reviewer found the provided records do not document that the requested scooter is not a 
replacement of an identical or nearly identical item that you have already been provided within the last 5 years. 
The records do not document that your present group 2 power mobility device has been lost, stolen, irreparably 
damaged in a specific accident or natural disaster or has reached its reasonable useful lifespan to meet 
Medicare criteria for replacement. Our reviewer also found that the provided records do not document that the 
requested item is medically necessary due to a change in your medical condition. 
 
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 replacement power operated vehicle have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a replacement power operated vehicle (K0812).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a cleaning (D1110), and 
a resin-based composite (D2330) provided by an out-of-network provider on October 18, 2022, and January 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan always covered the dental services 
form the provider and you would like the Plan to cover the dental charges. 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 a periodic oral evaluation (D0120), a cleaning (D1110), and a resin-based composite (D2330) 
provided by an out-of-network provider on October 18, 2022, and January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery (D4266), implant placement (D6010), and 
a bone replacement graft (D7953) for tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary, and you need he treatment done before it impacts your health. The Plan denied your request. The 
Plan says the denial of authorization for these services is correct, because the gum surgery, bone replacement 
graft, and implant services are not covered by the Plan. 
 
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 pre-approve gum 
surgery (D4266), implant placement (D6010), and a bone replacement graft (D7953) for tooth #30.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from 
January 29, 2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from January 29, 2023, to February 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection. You say that the requested electronic is necessary 
for the enrollee's power wheelchair. The Plan denied your request. The Plan says an electronic connection 
cannot be covered as it is not medically necessary to control the approved power option through the joystick 
(drive interface). The Plan also says this request exceeds the enrollee's need and is not reasonable and 
necessary per Medicare criteria. 
 
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. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the requested electrical accessories are not medically necessary as the enrollee does 
have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. 
 
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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and one power seating 
system motor (E2310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre. You asked the Plan to pre-approve a Freestyle Libre. You say that you are requested reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 
and does not have a history of problematic hypoglycemia. Based on this information, we decided that Medicare 
rules for coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service May 31, 
2022, to June 29, 2022. You asked the Plan to pay for the billed services. You say that the NOA was processed. The Plan denied your 
request. The Plan says the NOA was not received timely.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 2, 2022. The NOA was not received by the Plan until December 19, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for 
dates of service May 31, 2022, to June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient mental health services provided from September 23, 2022, to 
September 27, 2022. 
 
You asked the Plan to pay for inpatient mental health services. You say that you have correctly billed the 
services at issue. The Plan denied your request. The Plan says that rules for payment are not met. 
 
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. Specifically, the Plan's denial states that the claim has been reported with an 
incorrect patient status (or discharge status) code. The Plan has cited rules and regulations that do not discuss 
the reporting of patient status or discharge status codes. The Plan's citations do not support the denial rationale. 
It is the Plan's responsibility to support its denial with evidence. In this case, the denial is not supported, so we 
must find in your favor. Therefore, we decided that the Plan has to pay for inpatient mental health services 
provided from September 23, 2022, to September 27, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 17, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says self-administered drugs do not fall under Medicare Part B coverage. 
   
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on January 17, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you need 
these rides to your urology appointments. The Plan denied your request. The Plan says you have already used 
the maximum number of one-way non-emergency transportation trips this year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the plan to approve additional 
trips for your urology appointments. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional non-emergency transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 14, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
with the incorrect DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange.  
 
We looked at the file and Medicare rules. The requested testing is not registered and is not covered under the 
DEX Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided on 
February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you need this seat when you 
cannot reach high and there is nobody to help you. You also say that this is medically necessary equipment. 
The Plan denied your request. The Plan says a power seat elevation system is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the radiologic and physical exam findings support denial because they 
demonstrate other pathologic conditions that are unlikely to benefit from the Intracept procedure. 
 
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 items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found there is no magnetic resonance imaging showing only modic endplate changes and no 
foraminal stenosis. The cause of back pain is not clear. 
 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 (64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee is still somewhat unstable and requires additional acute care services that 
can be safely provided at the current facility until more stable and appropriate for transfer. The enrollee does 
not require services at the LTACH that are not already available at the current facility. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.