Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional meal delivery services. 
 
You asked the Plan to pre-approve the services. You say that you are requesting additional meals for the 
member. The Plan denied your request. The Plan says you exhausted your benefit. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. The member was last discharged from a hospital on September 5, 
2020. The Plan verified with the meal vendor that the member has used 14 of the allotted 14 meals from 
September 18 ? 30, 2020. The member has 0 meals remaining. This request is not covered by the member's 
health plan. Therefore, we decided that the Plan does not have to pre-approve additional meal delivery services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-invasive ventilator. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 DME. Our physician reviewer 
found coverage criteria for a home ventilator are not met. This patient has COPD, but there is no 
documentation of CO2 retention with an arterial blood gas while the patient is in a stable state.  The patient 
does not have neuromuscular disease or thoracic restrictive disease. Medicare does not cover a ventilator when 
used as BiPAP.  The medical records indicated the patient benefited from BiPAP while in the hospital.  A home 
ventilator is not medically necessary, and the denial is upheld. 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 DME have 
not been met. Therefore, we decided that the Plan does not have to pre-approve non-invasive ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove FreeStyle Libre continuous glucose monitor (CGM) and 
supplies (K0553) 
 
You asked the Plan to preapprove the CGM. You say that the claim should be paid. The Plan denied your 
request. The Plan says the required criteria has not been met, the request for the continuous glucose monitor 
cannot be approved as reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove 
FreeStyle Libre continuous glucose monitor (CGM) and supplies (K0553)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness 
and electronic connection. 
 
 
 
You asked the Plan to pre-approve the expandable controller, harness and electronic connection. You say that 
you would like reconsideration because these accessories are medically necessary. The Plan denied your 
request. The Plan says these accessories exceed the member's needs. 
 
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 expandable controller, harness and 
electronic connection. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not 
support that there is a medical need to control the power wheelchair with a joystick. 
 
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 expandable controller, harness and electronic connection have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller, expandable 
controller harness and electronic connection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 11,2020 
and billed under codes 30999 and 44500. 
 
You asked the Plan to pay for code 44500. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 44500 is described as ?a long, Miller-Abbott style gastrointestinal tube with a 
mercury-filled balloon at the bottom is introduced, usually nasally, and used to clear gastrointestinal strictures.? 
Inserting this feeding tube using a stylus is not synonymous with a long Miller Abbot GI tube therefore this 
service (44500) cannot be approved. CMS does not have a CPT code for insertion of an NGT without 
fluoroscopy. As this is an unlisted code without a fee listed in the Medicare fee schedule, payment cannot be 
made as billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, code 44500 cannot be paid as billed 
under Medicare guidelines as there are no fee structures listed for this code. Medicare billing criteria are not 
met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
July 11,2020 and billed under codes 30999 and 44500.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and attachments to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that medically necessary care 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 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 
a power wheelchair and attachments to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has 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 that 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 the 
services are medically necessary. Our physician reviewer found the enrollee does require skilled nursing or 
therapy services on a daily basis. This beneficiary does meet severity of illness or intensity of service criteria 
for 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the requested CT scan of the thorax is 
medically necessary. The Plan denied your request. The Plan says that the requested CT scan of the thorax is 
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 CT scan of the thorax. Our reviewer 
says that the requested CT scan of the thorax is medically necessary. Our physician reviewer found the enrollee 
is with abnormal CT scan associated with viral infection with recommendation of follow up CT. Although the 
CT findings were coincident with the viral infection, it is important to do a follow up study on non-specific CT 
findings. The requested follow up CT scan is medically reasonable and necessary in this case. 
 
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 CT scan of the thorax have been met. Therefore, we decided that the Plan has 
to pre-approve a CT scan of the thorax.  
 
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 pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says there is no 
documentation of failure of, inability to tolerate, or contraindication to other available osteoporosis therapy. 
 
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 Prolia. Our physician reviewer found 
that this request is for Prolia to treat age-related osteoporosis without current pathological fracture. The 
documentation does not support a history of an osteoporotic fracture; or previous treatment, contraindication, 
or intolerance to Abaloparatide, Calcitonin, intravenous or oral bisphosphonate, Raloxifene, and Teriparatide.   
Step therapy, as outlined by the plan, requires this documentation. Without the support of the documentation, 
Prolia is not approved as step criteria is not met. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from December 28, 2019, through 
December 29, 2019. 
 
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided from December 28, 2019, through 
December 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 1, 2019 to 
July 10, 2019. 
 
You asked the Plan to pay for the acute inpatient level of care. You say that please consider this retro 
authorization appeal. You have enclosed clinical information to support your claim. The Plan denied your 
request. The Plan says the enrollee was insured under a different health plan on the date of admission. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. 
This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay 
ended. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided 
June 1, 2019 to July 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile x-ray services rendered on July 19, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. The provider billed procedure code R0070. This code has a PC/TC 
indicator of 3 and no PC payment. Therefore, we decided that the Plan does not have to pay for the mobile x-
ray services rendered on July 19, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
May 23, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 CPT code 99285 is not supported in the medical record. Specifically, this code was billed with 
diagnosis codes Z11.59, R1084, D693, R112. The first listed diagnosis code Z11.59 is Encounter for screening 
for other viral diseases. This code was not appropriate for the diagnoses billed. Based on this information, we 
decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on May 
23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (excluding final 
restoration) (D3330). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is 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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, molar 
tooth (excluding final restoration) (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on July 23, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the diagnosis code of B95.61 was denied because it did not include the appropriate 
primary code. Review of diagnosis code B95.61 in the ICD-10-CM manual indicates "Unacceptable Principal 
Diagnosis" code.  An "Unacceptable Principal Diagnosis" note indicates there is sequencing instruction that 
should be followed. CMS follows correct coding guidelines per the ICD-10-CM manual. The code edits 
invoked correctly. 
 
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 diagnosis code submitted is not 
allowed as a primary diagnosis code. Medicare billing criteria are not met. Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on July 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography (CPT Code 93306) provided on 
July 28, 2020, at an in-network provider. 
 
You asked the Plan to waive the copayment for the service. You say that you were told to send a note to let the 
Plan know that a wrong code was sent from the hospital for this bill. The Plan denied your request. The Plan 
says their research supports that the services were ordered and rendered by your primary care physician. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
Review of the file show that you had echocardiography on July 28, 2020, by an in-network provider. You are 
asked to pay a $110 copayment for the diagnostic service. Your EOC states that enrollees must pay a $110 
copayment for each in-network Medicare-covered radiological diagnostic service, not including X-rays, 
performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (CPT Code 93306) provided on July 28, 
2020, at an in-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from August 14, 2020, to 
August 16, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that you could not be discharged until the 
echocardiogram was completed. The Plan denied your request. The Plan says that the services could have been 
provided in an observation level of care. 
 
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. 
 
The file shows that the inpatient services you received were rendered by a contract provider. The file does not 
show that the Plan provided notice that the inpatient services would not be covered. Under Medicare rules, this 
means the inpatient services is considered approved by the Plan. Therefore, we decided that the Plan has to pay 
for the inpatient hospital services provided from August 14, 2020, to August 16, 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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (92004) provided on 
October 14, 2020. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you believe that you should 
not be charged a copayment. The Plan denied your request. The Plan says the copayment applied correctly in 
this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Medicare-covered eye exams.  
 
You have been asked to pay a $35 copayment for the medical eye exam. the medical eye exam falls within the 
Medicare-covered eye exams benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the medical 
eye exam (92004) provided on October 14, 2020.