Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy (97026) provided July 17, 2020. 
 
You asked the Plan to pay for infrared therapy. You say that see attached medical records with an addendum 
from the medical doctor. The Plan denied your request. The Plan says infrared therapy is considered not 
reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
infrared therapy (97026) provided July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested items. 
 
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 or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a continuous glucose monitor and supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on June 1, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that you should not have a copayment 
due to COVID-19. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
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 in-network specialist's office services.  
 
Review of the file shows that you received gynecology services on June 1, 2020. The services were not related 
to COVID-19 treatment. You have been asked to pay a $35 copayment for these services. These services fall 
within the in-network specialist's office services 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 specialist services rendered on June 1, 2020.
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 the services requested are medically 
necessary for the enrollee. The Plan denied your request. The Plan says LTACH services are not medically 
necessary. 
 
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 is no documentation provided necessitating admission to an LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from November 23, 2018, to 
July 22, 2019, 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 had network providers 
available who could have provided 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 from November 23, 
2018, to July 22, 2019, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from May 5, 2020, 
to May 31, 2020. 
 
You asked the Plan to waive the copayment for SNF care. You say that you cannot afford the copayment for 
the SNF services at this time. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. 
 
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 $0 
each day for days 1 to 20 and a $178 each day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This 
SNF stay lasted 27 days, resulting in a total copayment amount of $1,246. 
 
You have been asked to pay a $0 each day for days 1 to 20 and a $178 each day for days 21 to 100 for SNF 
care. SNF care falls within the Skilled Nursing Facility (SNF) care 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 SNF care provided from May 5, 2020, to May 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99292) provided to the enrollee 
on August 5, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99292 (four units) remains 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 99292 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; each additional thirty minutes (List separately in addition to code 
for primary service." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation submitted was reviewed and does not meet the criteria. The documentation supports 167 
minutes, the first 74 minutes would be reported with CPT 99291, then the remaining 93 minutes divided by 
thirty equal three units to report with CPT 99292. Therefore, only three units would be supported. 
 
We looked at this coder'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 pay for critical care services (CPT 99292) provided to the enrollee on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose supplies (HCPCS A4253, A4256, A4258, 
A4259) provided to the enrollee from May 7, 2020, to August 6, 2020. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies. 
 
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 the denied codes is: 
 
HCPCS A4253: 
 
Normal, low, and high calibrator solution/chips 
 
HCPCS A4256: 
 
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips 
 
HCPCS A4258: 
 
Spring-powered device for lancet, each 
 
HCPCS A4259: 
 
Lancets, per box of 100 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the supplies. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
documentation did not include a delivery ticket with itemized supplies. Therefore, these codes cannot be 
verified as delivered. 
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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for blood glucose supplies (HCPCS A4253, A4256, A4258, A4259) provided to the enrollee from 
May 7, 2020, to August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab (with Paclitaxel and Carboplatin) for 
the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is needed for treatment of the adenocarcinoma. 
The Plan denied your request. The Plan says the next step would be molecular testing. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found EGFR and ALF 
wildtype is needed to approve. This request can be added when molecular studies are available. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Pembrolizumab (with Paclitaxel and Carboplatin) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation rendered on September 17, 
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. Medicare rules say that separate payment for code 85060 may only be 
made if the physician interpretation is done in an inpatient hospital setting. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an 
office setting. Separate payment can only be made for these services when performed in an inpatient hospital 
setting. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation rendered on 
September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot, ankle feature, and other parts for a 
prosthetic leg. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request exceeds medical need. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the treating medical practitioner progress note documentation and the patient activities noted do not 
support that you are a K3 level. 
 
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 an advanced foot, ankle feature, and other parts for a prosthetic leg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, and bitewings 
provided on September 15, 2020, by an OON provider. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, and bitewings. You say that you were 
not made aware that your dentist was no longer in-network. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says you did not contact the Plan prior to the date of 
service to verify benefits and provider eligibility. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis, periodic oral evaluation, and bitewings provided on September 15, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear (V2100 RT and LT) provided to the enrollee on 
February 28, 2020. 
 
You asked the Plan to pay for the services. You say that the services were essential for the enrollee's health and 
were provided in good faith. The Plan denied your request. The Plan says the maximum allowed amount for 
this benefit has already been received. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $165 maximum benefit per year. 
 
 
We looked at the file and the Plan's rules. The enrollee has already received the maximum $165 payment for 
these services for the year. Based on this information, we decided that the Plan's rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for eyewear (V2100 RT 
and LT) provided to the enrollee on February 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the cold capping therapy services received from May 1, 
2020, to June 2, 2020. 
 
You asked the Plan to pay for the cold capping therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services received are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the cold capping therapy services. Our 
reviewer says that the services received are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation shows that the services were provided to prevent or lessen the 
amount of hair loss caused by chemotherapy treatments for cancer. The medical records were not provided to 
support that these services were medically necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member. Therefore, you do not meet criteria for the services 
received. 
 
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 cold capping therapy services have not been met. Therefore, we decided that 
the Plan does not have to pay for the cold capping therapy services received from May 1, 2020, to June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. Finally, there is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care billed with a diagnosis code of unspecified 
severe protein-calorie malnutrition (E43) provided on November 13, 2018, to November 16, 2018. 
 
You asked the Plan to pay for inpatient hospital care. You say that the diagnosis code billed is supported by the 
medical records. The Plan denied your request. The Plan says the medical records do not support the diagnosis 
unspecified severe protein-calorie malnutrition (E43). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. DRG 180 is defined as Respiratory 
Neoplasms with Major Complication or Comorbidity. 
 
In this case, you billed the services provided November 13, 2018, to November 16, 2018 with DRG 180. We 
asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient hospital care. Our reviewer says 
that the medical records do not support the diagnosis code billed of unspecified severe protein-calorie 
malnutrition (E43). Our physician reviewer found the review indicates that the enrollee had a 15-pound weight 
loss in the past 3 weeks before admission. The admission weight was 83.1 kg with a BMI of 32.5 kg/m2. The 
ideal body weight is 52.38 kg. Muscle mass was noted to be normal. There was mild loss of triceps fat. There 
was no edema or anasarca. The review has determined that the medical documentation did not support the 
diagnosis code billed of E43, unspecified severe protein-calorie malnutrition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate DRG 180. Therefore, we decided that the Plan does not have to pay for 
inpatient care billed with a diagnosis code of unspecified severe protein-calorie malnutrition (E43) provided on 
November 13, 2018, to November 16, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for LDCT (G0297) provided on September 18, 2020. 
 
You asked the Plan to pay for the LDCT. You say that you would like reconsideration because this service was 
medically necessary and billed correctly. The Plan denied your request. The Plan says the diagnosis code 
submitted does not indicate if the member is or was a smoker. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code G0297 is not supported in the medical record. Specifically, the submitted 
documentation does not include a written order for this service. Additionally, the claim has not been billed with 
an appropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of the 
LDCT have not been met. Therefore, we decided that the Plan does not have to pay for LDCT (G0297) 
provided on September 18, 2020.