Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99308) 
rendered on August 7, 2023. 
 
You asked the Plan to pay for the services. You say that the medical documentation substantiates the need for 
these services, including all findings and information supporting medical necessity and justification for the 
services. The Plan denied your request. The Plan says the evaluation and management services were not a 
distinct and separate service.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record describes 
wound assessment and wound care; however, the record does not include documentation of significant, 
separately identifiable evaluation and management (E/M) services above and beyond that associated with the 
wound care provided, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99308) rendered on August 7, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance devices. 
 
You asked the Plan to pre-approve bioimpedance devices. 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 bioimpedance devices. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical trial supporting use of bioimpedance spectroscopy was used with the 
following indications: mastectomy/partial mastectomy, axillary treatment (dissection, sentinel lymph node 
biopsy [sentinel lymph node biopsy (SLNB)] less than 6 nodes or radiation), radiation therapy (chest 
wall/breast, supraclavicular fossa), or taxane-based chemotherapy. She met the criteria by having a partial 
mastectomy and this is medically reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bioimpedance devices have been met. Therefore, we decided that the Plan has 
to pre-approve bioimpedance devices.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requirements were not met for this admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing or skilled therapy needs. The enrollee is not fully participating in therapy, due to 
both medical and behavioral reasons. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an x-ray, and the abatacept injections 
provided on October 27, 2022, to May 30, 2023. 
 
You asked the Plan to waive the cost share for an x-ray, and the abatacept injections. You say that you disagree 
with the cost share. 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 chemotherapy and other drugs covered by Medicare Part B. Your contract with the Plan also 
clearly says that you must pay a $130 copayment for each covered x-ray in the outpatient department of a 
network hospital or facility. 
 
You have been asked to pay $77.47, which is less than the standard copayment for the x-ray provided on 
January 11, 2023. 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. 
 
You have also been asked to pay $391.21, which is less than 20% coinsurance of the allowed amount for the 
injection provided on October 27, 2022. You have also been asked to pay $864.92, which is 20% coinsurance 
of the allowed amount for the injection provided on November 29, 2022 ($4,325.60 allowed amount x 20% = 
$864.92).  You have also been asked to pay $869.96, which is 20% coinsurance of the allowed amount for each 
injection provided on January 5, 2023, February 2, 2023, March 2, 2023, March 30, 2023 ($4,349.80 x 20% = 
$869.96). You have also been asked to pay $855.22, which is 20% coinsurance of the allowed amount for the 
injection provided on April 27, 2023 ($4,276.10 allowed amount x 20% = $855.22). You have also been asked 
to pay $761.42, which is less than 20% coinsurance of the allowed amount for the injection provided on May 
30, 2023. These items/services fall 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. Therefore, we decided that the Plan 
does not have to waive the cost share for an x-ray, and the abatacept injections provided on October 27, 2022, 
to May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulator implant. 
 
You asked the Plan to pre-approve the services. You say that the enrollee has tried and failed other therapies 
and reports pain. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered experimental/investigational for peripheral diabetic neuropathy. Therefore, the 
request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electrical stimulator implant.
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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate care is currently 
unstable for transfer to an LTACH. 
 
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 there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services provided on June 5, 2023. 
 You asked the Plan to pay for the transportation services. You say that you would like your money to be 
reimbursed because this benefit is included in your policy. The Plan denied your request. The Plan says this 
service is not covered by Medicare. 
 
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 routine transportation when you contact the Plan's transportation vendor at least 48 hours 
in advance to schedule non-emergent transportation services.  
 
We looked at your request, the records in the case file, and the rules. The record shows that you did not contact 
the Plan's transportation vendor to schedule transportation at least 48 hours in advance. Based on this 
information, we decided that the Plans rules for coverage of routine transportation have not been met. 
Therefore, we decided that the Plan does not have to pay for the transportation services provided on June 5, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy (J9228) and Opdivo (J9299). 
 
You asked the Plan to pre-approve Yervoy and Opdivo. You say that these drugs are medically necessary and 
appropriate. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
these drugs. 
 
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 Yervoy and Opdivo. Our reviewer says that the requested drugs are not medically necessary in this case. Our physician reviewer found that the record 
indicates that the enrollee has a diagnosis of stage IV lung cancer previously treated with multiple courses of 
chemotherapy and has had disease progression while being treated with Keytruda. However, the Food and 
Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied; the requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy and Opdivo have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy (J9228) and Opdivo (J9299).
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 without the IRF services, the enrollee's health will be 
greatly jeopardized. The Plan denied your request. The Plan says the IRF services are 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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81209, 81223, 81241, 
81250, 81305, 81307, 81311, 81320, and 81334. We decided that the Plan does not have to pay for the services 
described by procedure code(s) 81279, 81321, 81339, and 81345.  
 
You asked the Plan to pay for procedure codes 81279, 81321, 81339, 81345, 81209, 81223, 81241, 81250, 
81305, 81307, 81311, 81320, and 81334 provided on June 24, 2023. You say that you would like the Plan to 
reconsider their denial of payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81209, 81223, 81241, 
81250, 81305, 81307, 81311, 81320, and 81334.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81209, 81223, 81241, 81250, 
81305, 81307, 81311, 81320, and 81334.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81279, 81321, 81339, and 81345. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 81279, 81321, 81339, and 81345 have not been met. Specifically, this claim was 
billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the services described by procedure 
code(s) 81279, 81321, 81339, and 81345. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2.  
You asked the Plan to pre-approve a FreeStyle Libre 2. 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 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 FreeStyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show that the enrollee requires daily skilled nursing and skilled 
therapy services in a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
appears to be functioning at/near her baseline. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition.  The enrollees care needs, custodial and 
intermittent, can, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure (22612). 
 
You asked the Plan to pre-approve the services. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested service is experimental/investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence-based medical guidelines and peer-reviewed literature do not fully support the 
interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large-
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. According to the FDA, The HA Minuteman G3-R MIS Fusion Plate is a posterior, non-pedicle supplemental fixation device, intended for use at a single level in the non-cervical spine 
(T1-S1). The HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft material and is not 
intended for stand-alone use. In addition, fusion indications within guidelines/literature for (existing or 
potential intraoperative) instability have not been documented and/or met in this case. In addition, there are 
multiple alternate pain generators plausibly significantly contributing to the clinical condition that have not 
been fully documented as having been excluded and/or ruled out. No compelling rationale is presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested Minuteman Procedure at L5-S1 is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman procedure (22612).