Persius/hicric huggingface dataset:
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 measurement of brain activity with video. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says it is not medically 
necessary for this service to be provided out of network. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve OON services. You say that the provider provides a unique disease 
management service. The Plan denied your request. The Plan says the requested service is available in-
network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a 
ventilator to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on May 4 - May 9, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you were in the ICU for five nights 
on ventilators, due to COVID-19. You say that an aneurysm developed after being taken off the ventilator and 
the catheter being removed. You say that the COVID-19 attacked your body, resulting in multiple visits in and 
out of the hospital. The Plan denied your request. The Plan says that they are upholding their decision to deny 
the claim because the records available do not describe the type of services provided. The Plan says that the 
provider did not describe how the services provided are not included in the already existent codes. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the inpatient hospital services by a contract provider. The file does not show that the 
Plan provided notice that the inpatient hospital services would not be covered. Under Medicare rules, this 
means the inpatient hospital services is considered approved by the Plan. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided on May 4 - May 9, 2020.  
 
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Apligraf (Q4101). 
 
You asked the Plan to pre-approve Apligraf. You say that the enrollee would benefit from Apligraf therapy. 
The Plan denied your request. The Plan says that this is only supported for clinically infected wounds. 
 
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 Apligraf. Our reviewer says that the 
requested Apligraf is considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee would benefit from Apligraf therapy as it would help avoid amputation and further spread of 
infection which is currently controlled with antiobiotics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Apligraf have been met. Therefore, we decided that the Plan has to pre-approve 
Apligraf (Q4101).  
 
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 heavy-duty extra wide hospital bed (item code 
E0303). 
 
You asked the Plan to pre-approve heavy-duty extra wide hospital bed. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because the enrollee does not meet the weight requirement for a heavy-duty extra wide hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty extra wide hospital bed is only 
covered if the enrollee's weight is more than 350 pounds but less than 600 pounds.  
 
We looked at the file and Medicare rules. The enrollee's weight is less than 350 pounds. Based on this 
information, we decided that Medicare rules for coverage of heavy-duty extra wide hospital bed have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty extra wide hospital bed 
(item code E0303).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve the oxygen concentrator. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says the clinical 
documentation received does not establish that the member has Severe Chronic Pulmonary Disease or 
symptoms related to lack of oxygen that can be improved using oxygen therapy. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 oxygen concentrator. Our reviewer 
says that the coverage criteria for a home oxygen concentrator are not met and supplemental oxygen is not 
medically necessary. Our physician reviewer found an arterial blood gas obtained while the patient was 
breathing room air did not meet Medicare criteria for oxygen need, with a pO2 less than or equal to 55. 
 
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 oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99239) provided on January 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the code was already 
paid. 
 
The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management 
service is payable per patient per hospital stay.  
 
We looked at the file and Medicare rules. The records show that CPT 99239 was processed and paid by the 
Plan for the hospital stay in question. This code can only be paid once per hospital stay. The requested services 
exceed the payable limit for this code. 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 the services 
(CPT 99239) provided on January 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 50mg Ubrelvy tablets. 
 
You asked the Plan to pre-approve the Ubrelvy. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition under Medicare Part B. 
 
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 pre-approve 50mg Ubrelvy tablets.  
 
Benefits for the Ubrelvy 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee's condition cannot be 
managed with less than daily skilled services. The Plan denied your request. The Plan says the enrollee's needs 
are custodial. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF.  The patient does not 
have complex wound care or other ongoing SNF level SN need. The patient's functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 
SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled 
nursing facility setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre System 14 day Kit. 
 
You asked the Plan to pre-approve the Freestyle Libre System 14 day Kit. You say that you would like 
reconsideration because this supply is medically necessary. The Plan denied your request. The Plan says the 
documentation does not include a log either from the member or specific records of the insulin dosing and 
sliding scale from the physician. 
 
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 Freestyle Libre System 14 day Kit. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided records do not indicate the enrollee is testing his glucose 
level frequently (four times daily) as required by the Medicare regulation for the device. 
 
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 Freestyle Libre System 14 day Kit have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Freestyle Libre System 14 day Kit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 8, 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 -53 modifier is not accepted. 
 
The Plan must follow Medicare rules. The rules say that modifier 53 represents a discontinued procedure under 
the Physician Fee Schedule. 
 
We looked at the file and Medicare rules. The provider submitted procedure code 63650 with modifier -53 
under the hospital outpatient prospective payment system. Modifier -53 is not accepted under this payment 
system. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on June 8, 
2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99350) and physical therapy services (97163) 
provided on September 10, 2019. 
 
You asked the Plan to pay for the home visit and physical therapy services. You say that you would like 
reconsideration because the services rendered were medically necessary. The Plan denied your request. The 
Plan says the billed codes do not appropriately reflect the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that a home visit cannot be billed by a physician unless the physician was actually present in the 
beneficiary's home and the services of a physical therapy assistant shall not be billed as services incident to a 
physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
In this case, the CPT Code Manual definition of code 97163 is physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; An examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and 
Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient 
and/or family.  
 
The CPT Code Manual definition of code 99350 is home visit for the evaluation and management of an 
established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A 
comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant 
new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the 
patient and/or family.  
 
We find that CPT codes 99350 and 97163 are not supported in the record. Specifically, the record indicates that 
these services were rendered by a physical therapy assistant. There is no evidence that the physician was 
present in the member's home. Additionally, the services of a physical therapy assistant cannot be billed 
incident to a physician service. Based on this information, we decided that Medicare rules for coverage of the 
home visit and physical therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the home visit (99350) and physical therapy services (97163) provided on September 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips. 
 
You asked the Plan to pre-approve the Accu-Chek Aviva Plus test strips. You say that you would like reconsideration 
because you usually get this supply somewhere else but they did not supply enough. The Plan denied your request. 
The Plan says it is not medically necessary to make a brand exception in this case. 
 
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 Accu-Chek Aviva Plus test strips. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided there is no documentation that 
the Accu-Chek Aviva Plus test strips are medically necessary as opposed to the health plan's preferred brands, 
One Touch or Contour brand test strips. 
 
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 Accu-Chek Aviva Plus test strips have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, 
and endodontic therapy provided on April 30, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-ray, and endodontic therapy. 
You say that you were not told that the provider was opted out of Medicare. The Plan denied your request. The 
Plan says these services were rendered by a provider that had opted out of Medicare. The Plan also says that 
payments are unable to be made for services provided by a dentist who was opted out of Medicare at the time 
of service under your plan. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation, first intraoral periapical x-ray, and endodontic therapy provided on April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure monitoring device. 
 
You asked the Plan to pre-approve the device. You say that your doctor insists that you get this. The Plan 
denied your request. The Plan says this is used for monitoring, not diagnosis or treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitoring device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 20, 2020. 
 
You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because the documentation does 
not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting 
- is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of 
lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on May 20, 2020.