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

 
We decided that the Plan has to pay for the subsequent hospital evaluation and management (EM) services 
provided on April 9, 2020 billed with code 99232. 
 
You asked the Plan to pay for the subsequent EM services. You say that this code should be paid as it 
accurately reflects the services rendered which were medically necessary. The Plan denied your request. The 
Plan says that this was correctly denied since the same provider was paid for code 99222 for the same date of 
service. Both 99222 and 99232 cannot be billed on the same date. 
 
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. The documentation included in the case file does not substantiate the Plan's 
denial rationale. It is stated that payment was made for code 99222 to this same provider on the same date. No 
evidence that this was either billed or paid was provided. As such, there is not sufficient information to support 
the denial of payment in this case. Therefore, we decided that the Plan has to pay for the subsequent hospital 
evaluation and management (EM) services provided on April 9, 2020 billed with code 99232.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services provided from November 
25, 2019 to January 22, 2020. 
 
You asked the Plan to pay for the services provided. You say that the enrollee is being treated for severe pain. 
The Plan denied your request. The Plan says the services as coded are not a covered benefit. 
 
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 S9328 is Home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment.  
 
We looked at the file and the rules. The requested CPT code is not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the home infusion therapy services provided from November 25, 2019 to January 
22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe medical services to be provided by an OON provider. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.Medicare rules saythat 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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met ata different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs canbe met at an alternate 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 nothave to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says the documentation does not reflect that the enrollee meets coverage 
criteria. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (CPT code 00320) provided on 
January 30, 2020. 
 
You asked the Plan to pay for CPT code 00320. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 00320 is Anesthesia for all procedures on esophagus, 
thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year or older. 
 
We find that CPT code 00320 is not supported in the medical record. Specifically, there were no medical 
records provided to verify if the services were billed appropriately per Medicare guidelines. Based on this 
information, we decided that Medicare rules for coverage of CPT code 00320 have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia services (CPT code 00320) provided on January 
30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urgent care services provided. 
 
You asked the Plan to pay for the urgent care services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules say that claims for services, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the urgent care services was not filed until June. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the urgent care services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator electrode, each (CPT Code 
L8680) and percutaneous implantation of neurostimulator electrode array, epidural (63650). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the records show that the 
member does not have a condition for which this treatment is medically necessary. The Plan states the member 
has not had maximal medical management and they have had a neurosurgical evaluation that indicates that a 
spinal cord stimulator is recommended. 
 
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 physician reviewer 
found it does not appear from the records provided for review that the member has any of these conditions. The 
closest relevant diagnosis would appear to be: "intractable pain caused by nerve root injuries, post-surgical or 
post-traumatic including that of post-laminectomy syndrome." However, there were no objective findings of a 
nerve root injury in this case. Rather, the member's neurological exam was non-focal. There was no clear 
evidence of a nerve root injury. Nor had the member undergone a surgical procedure. In this setting, the 
requirements for coverage as defined in the NCD do not appear to have been met in this case--given that the 
member does not have a diagnosis for which this service is covered. 
 
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 implantable neurostimulator electrode, each (CPT Code L8680) and percutaneous 
implantation of neurostimulator electrode array, epidural (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitoring system, including sensor patches.You asked the Plan to pre-approvea Freestyle Libre continuous glucose monitoring system, including sensor patches.. You say that you would like reconsideration because this equipment is medically necessary to help you better manage your health.The Plan denied your request. The Plan says the guidelines for coverage have not been met.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 tocarefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve aFreestyle Libre continuous glucose monitoring system, including sensor patches.Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria requires multiple shots of insulin per day and the record indicates that you are on 1 shot. Additionally, the record does not indicate why you are not able to check your blood glucose levels with a blood glucose meter.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aFreestyle Libre continuous glucose monitoring system, including sensor patches. have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitoring system, including sensor patches.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous blood sugar monitor with receiver and 
supplies. 
 
 
 
You asked the Plan to pre-approve the continuous blood sugar monitor with receiver and supplies.. You say 
that you would like reconsideration because the equipment is medically necessary. The Plan denied your 
request. The Plan says the information provided does not support that coverage criteria have been met. 
 
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 continuous blood sugar monitor 
with receiver and supplies. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record does not show that you have 
been checking your blood glucose levels 4x per day. 
 
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 continuous blood sugar monitor with receiver and supplies. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the continuous blood sugar monitor with 
receiver and supplies.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that ongoing home health services are 
medically necessary. The Plan denied your request. The Plan says that the services are not skilled and no longer 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing 
coverage of home care services.  
 
There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services 
at issue in this appeal. A request for the NOMNC was made to the health plan and the NOMNC was not 
received by the IRE. Therefore, we decided that the Plan has to pre-approve home health services.  
 
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 the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the stockings (E0105). You say that you'd had these services covered 
before. The Plan denied your request. The Plan says while that may have happened it was in error and Amazon 
is not an eligible participant in Medicare. 
 
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. The member received services at non-participating provider 
 who is not Medicare Certified for durable medical equipment therefore, the claim denied correctly, 
and the member is responsible for the entire cost of the care 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 lab services provided on June 18, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services should be covered based on medical 
necessity. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnosis 
listed on the claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing 
for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided 
on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sinus augmentation, tooth #13 (CPT Code D0611) and 
second stage implant surgery, teeth #12 & 13 (D7951). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit under the plan. 
 
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 this benefit. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve sinus 
augmentation, tooth #13 (CPT Code D0611) and second stage implant surgery, teeth #12 & 13 (D7951).
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 continues to require skilled 
nursing and/or skilled therapy services on a daily basis. The enrollee's progress with therapy has stalled, there is 
no indication that a transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled 
rehab services at the current inpatient rehab facility or be discharged to a lower level of care for custodial care. 
There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF 
for inpatient skilled rehab services 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been 
met. 
 
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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intent is palliative, and does not seem to meet the ASTRO model policy or generic 
indications for SBRT being able to encompass all sites of disease. It does not appear that the proposed 
treatment is furnished in accordance with accepted standards 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 SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for CT of the head (70450) provided on July 8, 2020. 
 
You asked the Plan to pay for CT of the head. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the diagnosis code billed is not listed as 
appropriate for PET imaging. 
 
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. There is no evidence that PET imaging is at issue in this case. Additionally, the 
Plan has not forwarded sufficient information to verify that payment was previously made for CPT code 70450. 
It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not 
substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for CT of the head 
(70450) provided on July 8, 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.