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

 
We decided that the Plan does not have to pay for an office visit provided on September 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on September 23, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete bilateral noninvasive physiologic studies of 
upper or lower extremity arteries, 3 or more levels (93923). 
 
You asked the Plan to pre-approve noninvasive physiologic testing. You say that the test is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. The enrollee's 
symptoms are neuropathic. The LBP is associated with LLE pain and calf numbness that is present when 
walking and at rest. The problem oriented physical exam does not support the requested arterial diagnostic 
workup. 
 
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 noninvasive physiologic testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has leg pain that has been diagnosed as being of lumbar spine 
origin and treated with epidural injections. The record provided does not document a vascular pulse 
examination. The record provided is insufficient to establish the medical necessity of the requested service. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of noninvasive physiologic testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve complete bilateral noninvasive physiologic studies of upper or lower 
extremity arteries, 3 or more levels (93923).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery (22558, 20936, 22585, 20930). 
 
You asked the Plan to pre-approve the spinal surgery. You say that the surgery is medically necessary. The 
Plan denied your request. The Plan says 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 the spinal surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no imaging studies showing spinal instability. There is no neurologic deficit on exam. 
Records do not support this service. 
 
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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve spinal surgery (22558, 20936, 22585, 20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
transmitter and sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 CGM transmitter and sensor. You say that the requested 
items are medically necessary for the enrollee due to her type 2 diabetes mellitus with diabetic polyneuropathy, 
with long term current use of insulin, uncontrolled. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Dexcom 
G6 CGM transmitter and sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Dexcom G6 continuous glucose monitor (CGM) transmitter and sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four COVID-19 test kits purchased on February 15, 
2022. 
 
You asked the Plan to pay for the COVID-19 test kits. The Plan denied your request. The Plan says these home 
test kits are not covered under the Medicare benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test kits are an OTC item. The contract says that the Plan offers a benefit program for the purchase 
of eligible OTC wellness items, which includes at-home COVID-19 test kits. The record shows that you can 
request reimbursement for these tests through the Plans OTC card portal online. Therefore, we decided that the 
Plan does not have to pay for the four COVID-19 test kits purchased on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and prolonged visit provided on January 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained before the services were rendered to 
the enrollee. 
 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 provider in this case is not a network provider with the Plan. 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 office visit and prolonged visit provided on January 21, 2022, 
by an out-of-network (OON) provider.
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 this service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has 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 in the Medicare rules section. 
 
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 while the enrollee would benefit from therapy services, the enrollee's needs can be 
met at a lower 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 not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on October 19, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you have provided the laboratory reports to support 
the service billed. The Plan denied your request. The Plan says that the documentation provided does not 
support the service billed. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the documentation does support 
that 22+ drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
the drug testing have been met. Therefore, we decided that the Plan has to pay for the drug testing provided on 
October 19, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on February 17, 
2022. 
 
You asked the Plan to pay for the initial hospital care (99223). You say that Place of service 21 is correct and 
can be separately paid per guidelines. You say that medical records are attached, and the claim should process 
to pay. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the inpatient POS was billed 
but the enrollee was an outpatient at the time the service. Based on this information, we decided that Medicare 
rules for coverage of the initial hospital care (99223) have not been met. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care (99223) provided on February 17, 2022.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does have documented skilled nursing needs, in the form of a new 
ostomy. The enrollee does have documented skilled therapy needs, as she appears to be functioning below her 
baseline. Daily skilled services are required to establish a maintenance program or to prevent deterioration of 
the enrollees condition. 
 
   
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the records do not support IRF admission. The records do not show 
that the enrollee needs rehabilitation nursing care 24 hours a day. Also, the records do not show the enrollee 
needs at least 3 doctor visits per week. Based on the enrollee's current needs they can receive the care they need 
in a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 that the enrollee is medically stable and does not need PM&R physician's supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. No acute rehabilitation nursing needs identified or documented. At the current functional 
mobility and medical status, the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. IRF admission is not 
medically necessary based lack of medical complexity and acute rehabilitation nursing needs. 
 
Documentation does not support the medical necessity for admission to an IRF. While the enrollee may benefit 
from continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely 
provided in a lower intensity and alternate setting such as in an SNF. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and will 
benefit from transferring to an LTACH. The Plan denied your request. The Plan says there is no documentation 
that the enrollee will benefit from and improve with LTACH management. The clinical assessment does not 
support the expectation of a stay to be at least 25 days. Criteria for admission to the LTACH has not been met. 
The enrollee's medical needs are being met in the current acute setting. With additional time in the current 
setting, clinical stability can be ensured such that the appropriate lower level of care can be determined. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 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. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0296). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you have had a total electric bed 
for the past 20 years, but the bed has exposed wires and the height adjustment does not work. You also say you 
need the height adjustment for the nurses when they come out to change the dressings to your feet. The Plan 
denied your request. The Plan says a total electric hospital bed is not covered by Medicare as the height 
adjustment feature is considered a convenience feature. You have been approved for a semi-electric hospital 
bed in April 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0296).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skelaxin tablets. 
 
You asked the Plan to pre-approve Skelaxin tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Skelaxin tablets are not covered under the enrollee's 
Medicare Part B benefit. The Plan also says, for further information, this medication is on the high-risk 
medication list and is not recommended in patients 65 years and older due to a higher risk potential for side 
effects. 
 
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 Skelaxin tablets.  
 Benefits for Skelaxin tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.