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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 7, 2022, 
through August 10, 2022, and billed with diagnosis code E43. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis E43 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of E43. 
 
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 secondary diagnosis code E43-severe malnutrition. 
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 documentation does not support the secondary diagnosis of E43-
severe malnutrition. Our physician reviewer found the member had a mild temperature and was diagnosed with 
hyponatremia and dehydration and given fluids. The notes also described the member as "well-nourished". The 
member had reduced oral intake except water over the prior 8 days and lost about 6 pounds (4.5% reduction). 
The member was given oral liquid diet. The member was not given supplemental nutrition or experienced 
weight loss of over 10% or has signs of malnutrition such as muscle wasting. The member's body mass index 
(B)MI was 24, and albumin was normal. Therefore, there was insufficient support made for using the diagnosis 
code, E43, severe protein calorie malnutrition.   
 
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 August 7, 2022, through August 10, 2022, and billed with diagnosis 
code E43.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept Intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative 
treatment. The Plan denied your request. The Plan says the treatment is considered experimental. 
 
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 requested services. Our physician 
reviewer found that the records do not contain magnetic resonance imaging showing only modic changes and 
not foraminal stenosis, or facet degenerative joint disease which can cause back pain. The cause of back pain is 
not clear. Therefore, the requested service 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept Intraosseous ablation of the basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that the ride benefit is 
your only mode of transportation for your specialist visits. The Plan denied your request. The Plan says 
additional coverage outside of your covered benefits is unable to be approved. 
 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 up to 48 one-way 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, or will 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frame (V2025), anti-reflective coating (V2750), 
and progressive lens (V2781) provided on November 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyewear. You say that you saved the Plan $100 by going to an OON 
provider. The Plan denied your request. The Plan says you received this eyewear from an OON provider. The 
Plan also says claims from a provider who is not in the Plan's network are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are obtained from a provider in the Plan's vision vendor 
network. 
 
 
 We looked at the file and the Plan's rules. Specifically, you received this eyewear from an OON provider, and 
your contract clearly states that services obtained from vendors outside the Plan's vision vendor network are not 
covered. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for the deluxe frame (V2025), anti-reflective 
coating (V2750), and progressive lens (V2781) provided on November 21, 2022, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the artificial lumbar disc replacement (22857). 
 
You asked the Plan to pre-approve the artificial lumbar disc replacement. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is considered experimental. 
 
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 artificial lumbar disc replacement. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 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 artificial lumbar disc replacement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the artificial lumbar disc replacement (22857).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation (D9310) and cone beam CT (D0364) provided 
on February 14, 2023. 
 
You asked the Plan to pay for consultation and cone beam CT. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
consultation (D9310) and cone beam CT (D0364) provided on February 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) provided on 
October 20, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the duplex scan. You say that you are classified as a silent provider, and are not 
liable or have the authority to obtain authorizations and/or take the necessary measures to ensure medical 
criteria are met for enrollees at the facility. You also say that you would like this claim to be reprocessed for 
payment. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider, 
and the provided information does not describe how the enrollee came to the servicing provider. The Plan also 
says in the absence of clinical information and medical necessity, coverage cannot be determined. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) 
provided on October 20, 2022, by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred product. 
 
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 Evenity. Our physician reviewer found 
that the enrollee has osteoporosis. The Plan requires a trial of Forteo before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating that the Plans required drug would likely be less effective and/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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulmonary walker/ wheelchair combo (E1399). 
 
You asked the Plan to pre-approve a pulmonary walker/ wheelchair combo. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item 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 a pulmonary walker/ wheelchair 
combo. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record does not support that you require a seated walker to ambulate 
safely in the home. 
 
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 pulmonary walker/ wheelchair combo have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pulmonary walker/ wheelchair combo (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart pulse generator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee remains at risk for 
additional heart failure hospitalizations. The Plan denied your request. The Plan says there is insufficient 
evidence of efficacy. 
 
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 requested services. Our physician 
reviewer found that you have heart failure with reduced ejection fraction due to nonischemic cardiomyopathy. 
The Optimizer (permanent cardiac contractility modulation device) is currently an investigational device and 
not endorsed or recommended by any professional societys guidelines for treatment of advanced heart failure. 
Therefore, the request 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Optimizer Smart pulse generator.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the ostomy supplies (A4371, A5120, A4414, A5063) provided on 
September 22, 2022, through September 23, 2022. 
 
You asked the Plan to pay for the ostomy supplies. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the recent request for colostomy supplies exceeds reasonable 
quantities. 
 
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 rules say the quantity of ostomy supplies needed by a beneficiary is determined primarily by the 
type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There 
will be variation according to individual beneficiary need and their needs may vary over time. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The dates of service were in 2022, and the Evidence of Coverage provided was 
for 2023; therefore, we cannot verify what services are covered under the Plan. Furthermore, the Plan did not 
provide any documentation to show if there were ostomy supplies provided and paid for by the Plan prior to 
this date of service. The documentation we have shows the provider did not exceed the maximum quantity of 
these supplies. Therefore, we decided that the Plan has to pay for the ostomy supplies (A4371, A5120, A4414, 
A5063) provided on September 22, 2022, through September 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
requested power wheelchair is medically necessary for the enrollee. The Plan denied your request. The Plan 
says equipment to be used in a skilled nursing facility cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a Group 3 power wheelchair with multiple power options is being requested for use in a 
SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
with multiple power options and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft  retained natural tooth  first site 
in quadrant (D4263) provided on November 17, 2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that the dentist told you that this is the 
correct procedure for this service and insurance companies are not up on the current guidelines. The Plan 
denied your request. The Plan says D4263 is non-covered if performed on the same date as an extraction. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft  retained natural tooth  first site in quadrant (D4263) provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown repair (D2980) provided on January 18, 2023. 
 
You asked the Plan to pay for crown repair. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown 
repair (D2980) provided on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve total electric hospital bed. You say that you are appealing this denial. The 
Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a total electric hospital bed.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says that the services 
requested are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a computed tomography (CT) scan. Our 
reviewer says that the service is medically necessary. Our physician reviewer found considering the history, 
recent cardiac device placement and decision to halt oral anticoagulants, the request for the exam is reasonable 
in order to ensure normal functioning of the implanted device and the lack of leakage and/or recurrent 
thrombus formation. 
 
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 computed tomography (CT) scan have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan.  
 
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 functional electrical stimulator (E0770). 
 
You asked the Plan to pre-approve a functional electrical stimulator. You say that this is medically necessary. 
The Plan denied your request. The Plan says the records do not show that you have disuse muscle atrophy with 
an intact neurologic supply, or that you had a spinal cord injury. 
 
The Plan follows Medicare rules. Medicare rules say that NMES can be covered when certain criteria are met. 
 
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 functional electrical stimulator. Our 
reviewer says that you do not meet criteria for coverage. Our physician reviewer found the record indicates that 
you have spastic hemiplegia in the setting of a distant stroke. The record provided does not establish that you 
have disuse atrophy where nerve supply to the muscle is intact or a spinal cord injury. 
 
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 functional electrical stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a functional electrical stimulator (E0770).