Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 1, 2020, to August 14, 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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We asked our coder 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 reviewer found the documentation does not support a 
diagnosis of malnutrition. The enrollee was started on oral nutrition supplement while hospitalized. The 
enrollee was admitted to the SNF on 7/29/20. The enrollee's nutrition was documented to be "Adequate" on 
7/30/20. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from August 1, 2020, to August 
14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), and Spherocylinde (V2103), provided 
on January 15, 2021. 
 
You asked the Plan to pay for the frames and Spherocylinde. You say that the services should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the frames (V2020), and Spherocylinde (V2103), provided on 
January 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested CGM. 
 
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 and does not 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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 11, 2020, to December 15, 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 the payment integrity post-service, post-payment Patient Driven Payment Model (PDPM ) 
clinical validation audit found that the provider has reported skilled services with the incorrect PDPM Health 
Insurance Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We asked our coder 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 reviewer found the available medical records do not 
support parenteral/IV feeding administration for the treatment of a diagnosis of dehydration. The available 
medical records do not support the presence of an acute neurological condition. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from December 11, 2020, to 
December 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from October 
4, 2021, to October 6, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says payment denied due to a billing error as it was submitted with the wrong Type of Bill 
code. Therefore, to proceed a corrected claim is required. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate type of bill code. In this case, this claim cannot be paid as 
billed due to an error with the type of bill code submitted. Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the 
enrollee from October 4, 2021, to October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen handling (99000) provided on August 12, 2021. 
 
You asked the Plan to pay for specimen handling. You say that this should be covered. The Plan denied your 
request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database 
(MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment 
for other services not specified. 
 
 
  
We looked at the file and Medicare rules. Code 99000 has a status indicator or B and cannot be paid separately. 
Based on this information, we decided that Medicare rules for coverage of specimen handling have not been 
met. Therefore, we decided that the Plan does not have to pay for specimen handling (99000) provided on 
August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) rendered by the out-of-network 
(OON) provider on June 28, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99205) rendered by the out-of-network (OON) provider on June 28, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided May 31, 2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the documentation does not support 
payment for an additional unit of subsequent hospital care coded 99232. 
 
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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that payment for an additional unit of CPT code 99232 is not supported in the medical record. 
Specifically, the documentation provided does not support that an additional unit of 99232 was rendered on the 
date in question. Based on this information, we decided that Medicare rules for coverage of the subsequent 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99232) provided May 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durysta (J7351). 
 
You asked the Plan to pre-approve Durysta. You say that Durysta is medically necessary. The Plan denied your 
request. The Plan says repeat use of Durysta is not medically necessary. 
 
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 Durysta. Our reviewer says that 
Durysta is not medically necessary. Our physician reviewer found the Medicare-approved major drug 
compendia specifically state that Durysta is not to be re-administered to an eye with a prior bimatoprost 
intracameral implant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durysta (J7351).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cold cap. 
 
You asked the Plan to pre-approve the cap. You say that this is needed to prevent hair loss during 
chemotherapy infusion. The Plan denied your request. The Plan says this is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that items meant to keep the head cool during chemotherapy are not separately 
covered.  
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cold cap.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on November 9, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit since it was performed for a medical reason. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81528) provided April 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was provided to support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Insufficient clinical records were provided to support the billed 
service. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of lab services (81528) provided April 22, 2021. have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (81528) provided April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on July 9, 2021. 
 You asked the Plan to pay for the gene panel. The Plan denied your request. The Plan says experimental or 
investigational services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that biomarkers are only covered under certain 
medical indications. 
 
We looked at the file and Medicare rules. The file shows that the enrollee has non-Hodgkins lymphoma. A 
targeted genomic sequence analysis panel of 51 or greater genes was provided. The records do not demonstrate 
that the biomarkers will be used to assist in the management or treatment of the enrollees condition. Based on 
this information, we decided that Medicare rules for coverage of the gene panel have not been met. Therefore, 
we decided that the Plan does not have to pay for the gene panel provided on July 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care from September 9, 
2021, to September 29, 2021. 
 
You asked the Plan to pay for SNF care. You say that you were not advised the services would not be covered. 
The Plan denied your request. The Plan says the services were not medically necessary and do not meet 
Medicare criteria for coverage.  
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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you did not have daily skilled nursing needs 
that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have 
daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) 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 not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) care from September 9, 2021, to September 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 24, 2020, to August 31, 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 the payment integrity post-service, post-payment Patient Driven Payment Model (PDPM) 
clinical validation audit found that the provider has reported skilled services with the incorrect PDPM Health 
Insurance Prospective Payment System (HIPPS) score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We asked our coder 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 reviewer found the provider billed PDPM score 
GAGD1. This includes the nursing component billed as "Special Care High" which requires actively treated 
COPD with documentation of shortness of breath while lying flat. The available documentation in the case file 
does not support that the enrollee had shortness of breath while lying flat. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from August 24, 2020, to 
August 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on October 
14, 2021, through November 14, 2021. 
 You asked the Plan to pay for the SNF care. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the service was 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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the member did not have any skilled therapy 
or skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Specifically, medically necessary services 
could be obtained in a lower level of care. Therefore, we decided that the Plan does not have to pay for the 
skilled nursing facility (SNF) care, provided on October 14, 2021, through November 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for a hearing aid provided on 
October 13, 2021. 
 
You asked the Plan to reimburse an additional amount for the hearing aid. The Plan denied your request. The 
Plan says the hearing aid benefit does not provide out-of-network coverage. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans hearing vendor. 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The file shows that the hearing aid was not provided by the Plans 
hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aid 
have not been met. Therefore, we decided that the Plan does not have to reimburse an additional amount for a 
hearing aid provided on October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Touch Ultra test strips for the enrollee. 
 
You asked the Plan to pre-approve One Touch Ultra test strips. You say that these are medically necessary. The 
Plan denied your request. The Plan says that there are no medical reasons given the enrollee can't use the 
preferred systems. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
 
 
 
 We looked at the file and Medicare rules. The file does not include any documentation from why the enrollee 
requires this specific brand of blood glucose test strips. Without this, medical necessity cannot be established. 
Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra test strips for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to receive the physical therapy you 
need in the hospital. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
coverage. 
 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility SNF 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.