Persius/hicric huggingface dataset:
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 would like reconsideration because 
the LTACH services are medically necessary. The Plan denied your request. The Plan says the guidelines for 
coverage have not been met. 
 
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 available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on June 18, 2020. 
 
You asked the Plan to pay for the extraction. You say that you feel this service was due to medical reasons, and 
should be covered. The Plan denied your request. The Plan says the extraction is not a covered benefit. The 
Plan also says that the extraction is a comprehensive dental service, and you did not purchase the 
comprehensive dental supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 the primary dental plan. Therefore, we decided that the Plan does not have to pay 
for the extraction provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room and related services provided on May 
26, 2019. 
 
You asked the Plan to pay for the emergency room and related services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 find that the emergency room and related services are not supported in the medical record. Specifically, 
these services were not billed with a valid provider type. Based on this information, we decided that Medicare 
rules for coverage of the emergency room and related services have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency room and related services provided on May 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter. 
 
You asked the Plan to pre-approve an electric scooter. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 electric scooter. Our reviewer says 
that the documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found you have a medical history of a closed fracture of the right ankle with delayed 
healing. The documentation supports that you are able to ambulate short distances with a walker and also use a 
manual wheelchair. The documentation supports that your mobility deficit can be helped by the use of a 
walker, cane, or manual wheelchair. Therefore, you do not meet criteria for the requested item. 
 
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an electric scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on May 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 27369 and 77002 are not supported. 
 
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 27369 is injection procedure for contrast knee 
arthrography or contrast enhanced CT/MRI knee arthrography. The definition of code 77002 is fluoroscopic 
guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition 
to code for primary procedure). 
 
We find that CPT codes 27369 and 77002 are not supported in the medical record. Specifically, there is no 
documentation of an injection for knee arthrography for the billed date of service to support code 27369. Given 
that the primary procedure code 27369 is not supported, add-on code 77002 is also not supported. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the injection services rendered on May 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-preferred brand of test strips. 
 
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee wants to use 
the non-preferred brand of test strips. The Plan denied your request. The Plan says there is no medical reason 
documented that you are medically unable to use the Plan preferred test strips. 
 
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. There is no physician documentation that the non-preferred brand is 
necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for 
coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the non-preferred brand of test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre therapeutic continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre therapeutic CGM. You say that the items 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 CGM devices covered when specific criteria is 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 FreeStyle Libre therapeutic CGM. 
 
 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee does not 
satisfy the coverage criteria for the requested therapeutic CGM. As such, the therapeutic continuous glucose 
monitor (CGM) and related supplies are 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 a FreeStyle Libre therapeutic CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a FreeStyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for the oral exam (D0120), prophylaxis (D1110), 
and unspecified preventive procedure (D1999) provided on June 3, 2020. 
 
You asked the Plan to reimburse more for the dental services. You say that per the Summary of Benefits, 
routine dental services that you receive out of network are covered at 50%. You say that the plan should have 
paid more than the $35.50 that you were reimbursed. The Plan denied your request. The Plan says the claim 
processed correctly. The Plan says that the appropriate copayment was applied correctly. The Plan also says 
that unspecified preventive procedure is not listed as 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 Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan pays services you receive out 
of network based on the in network fee schedule (allowed amount). The Evidence of Coverage states that you 
are responsible for the difference between the billed amount and the allowed amount in addition to the 
copayment amount. 
 
 
CPT Code Billed Amount Allowed Amount Copayment Plan Paid Your Responsibility 
D0120 $76 $24 $12 $12 $64 
D1110 $107 $47 $23.50 $23.50 $$83.50 
D1999 $15.90 $0 $0 $0 $15.90 
TOTAL:     $163.40 
 
 
Therefore, we decided that the Plan does not have to reimburse more for the oral exam (D0120), prophylaxis 
(D1110), and unspecified preventive procedure (D1999) provided on June 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on March 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 95999. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows 
that Train of Four testing was provided and there is a more appropriate code for these services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the testing services rendered on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 sensor. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors (CGMs) are only 
covered when the enrollee has been using a blood glucose monitor and performing frequent (four or more times 
a day) testing. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee is testing their blood sugars 
three times per day. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
sensor.
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 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. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehab 
services at a lower level of care. Although further rehab services would be appropriate to improve function, as 
a practical matter, the daily skilled services can be provided at a lower level of care than a skilled nursing 
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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound provided on June 4, 2020. 
 
You asked the Plan to pay for the breast ultrasound. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 76642 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; limited. 
 
We find that CPT code 76642 is not supported in the medical record. Specifically, this code requires an 
anatomical modifier (LT, RT, or 50) to be appended to specify the nature and location of the procedure. Based 
on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. 
Therefore, we decided that the Plan does not have to pay for the breast ultrasound provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty semi-electric position bed (E0301). 
 
You asked the Plan to pre-approve a heavy duty semi-electric position bed. You say that the item is 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 heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds, but does not exceed 600 pounds. 
 
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 heavy duty semi-electric position bed. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee does not 
satisfy the coverage criteria for the requested heavy duty, extra wide hospital bed. 
 
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 heavy duty semi-electric position bed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy duty semi-electric position bed (E0301).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve the Retacrit. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet medical criteria 
for coverage of Retacrit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the Retacrit. Our reviewer says that 
documentation does not support the enrollee has been treated with iron supplementation to increase ferritin 
levels greater than 100mcg/mL. Our physician reviewer found without this documentation, retacrit cannot be 
determined 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 Retacrit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 8, 2020 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. 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 medical services provided on June 8, 2020 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services to be provided by an OON provider. 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. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered from June 17, 2019 to July 
3, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation 
setting and should have been billed with POS code 32.  
 
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 P9604 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge. 
We find that CPT code P9604 is not supported in the medical record. Specifically, there is no documentation of 
a travel allowance for the laboratory specimen. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered from June 17, 
2019 to July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound therapy rendered on March 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan contract says that non-Medicare covered 
chiropractic services are covered when provided in conjunction with the visit specifically for spinal or joint 
adjustment. 
 
The records show that you received ultrasound therapy on March 24, 2020 without spinal or joint adjustment. 
Based on this information, we found that the Plan?s rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound therapy rendered on March 24, 
2020.