Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) billed for date 
of service January 21, 2022. 
 
You asked the Plan to pay for hospital discharge management. You say that this service was reported correctly 
and is supported as billed. The Plan denied your request. The Plan says the medical records provided do 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records provided 
do not note the time spent providing this service. Without this information, a time-based code such as 99239 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of hospital 
discharge management have not been met. Therefore, we decided that the Plan does not have to pay for 
hospital discharge day management (99239) billed for date of service January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infusion services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve infusion services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because this provider 
is out-of-network with the Plan and you can be treated by an in-network provider. 
 
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 
infusion services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute 
rehabilitation to optimize her level of functioning prior to returning home. You say that enrollee requires 
interdisciplinary therapy care. You say that the enrollee has serious, life-threatening constellation of acute 
medical problems that left her at a functional status below her baseline. The Plan denied your request. The Plan 
says IRF care is not medically necessary. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that she 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. 
The enrollee can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker, folding wheeled (E0143), a walker 
seat attachment (E0156) and a brake attachment for wheeled walker (E0159). 
 
You asked the Plan to pre-approve a rollator walker and accessories. You say that you need the walker due to 
knee pain. You are overweight and cannot walk without help. You also say you denied receiving a walker in 
2019. The Plan denied your request. The Plan says you do not meet the criteria for a rollator walker because 
you have not owned your current equipment for more than 5 years. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you received a walker, heavy duty, multiple braking system, variable wheel resistance 
(E0147) and accessories on October 26, 2019. The walker received in 2019 serves the same purpose as a 
rollator walker and accessories. The Medicare guidelines show that the reasonable useful lifetime of DME 
equipment is 5 years. Therefore, we decided that the Plan does not have to pre-approve a rollator walker, 
folding wheeled (E0143), a walker seat attachment (E0156) and a brake attachment for wheeled walker 
(E0159).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from November 25, 2020, to 
October 5, 2021. 
 
You asked the Plan to pay for hospital services. You say that you are certified to participate in Medicare. The 
Plan denied your request. The Plan says this provider does not participate in the Medicare program and is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a provider must be enrolled in the Medicare 
program to receive payment for covered items or services.  
 
We looked at the file and Medicare rules. This provider is not enrolled in the Medicare program and is 
therefore not payable. Based on this information, we decided that Medicare rules for coverage of hospital 
services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services 
provided from November 25, 2020, to October 5, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rivastigmine. 
 
You asked the Plan to pre-approve Rivastigmine. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Rivastigmine.  
 
Benefits for Rivastigmine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 80061, 83036, 85025, 80053 
and 87522 provided November 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please see attached medical records. The 
Plan denied your request. The Plan says services is not covered by Medicare. 
 
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. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services coded as 
80061, 83036, 85025, 80053 and 87522 provided November 10, 2021. have been met. Records was requested 
from the provider to determine how the enrollee came to the servicing provider or whether the services are 
medically necessary. The Plan made multiple attempts to obtain the additional records from the provider 
without success. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 
80061, 83036, 85025, 80053 and 87522 provided November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for an opioid treatment program provided from April 4, 2022, to  
April 18, 2022. 
 
You asked the Plan to pay for an opioid treatment program. The Plan denied your request. The Plan says that 
the services do not meet the opioid treatment program criteria for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided us with the rule to support their denial. 
Therefore, we decided that the Plan has to pay for the opioid treatment program (code G2080) provided from  
April 4, 2022, to April 18, 2022.  
 
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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care services provided from January 13, 2022, to 
January 28, 2022. 
 
You asked the Plan to pay for the home health care services. You say that the Notice of Admission (NOA) for 
this claim was submitted on January 13, 2022, and you would like this claim to be reprocessed. The Plan 
denied your request. The Plan says that the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the documentation submitted does not include any evidence to 
support why this claim was denied. The file includes a Notice of Admission (NOA) and there is no indication 
of a discrepancy between the dates of service at issue. The Plan has not clearly stated why these claims are not 
valid. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plans 
denial is not substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the 
home health care services provided from January 13, 2022, to January 28, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio peripheral nerve stimulator device and 
supplies. 
 
You asked the Plan to pre-approve a Cala Trio peripheral nerve stimulator device and supplies. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that while electric nerve stimulation has been employed to 
control chronic intractable pain for some time, its use in the treatment of motor function disorders, such as 
multiple sclerosis, is a recent innovation, and the medical effectiveness of such therapy has not been verified by 
scientifically controlled studies. 
 
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 Cala Trio peripheral nerve stimulator 
device and supplies. Our reviewer says that the services are not medically necessary.  Our physician reviewer found the documentation indicates that the enrollee has been diagnosed with benign 
essential tremor worse on right than left. The NCD states: While electric nerve stimulation has been employed 
to control chronic intractable pain for some time, its use in the treatment of motor function disorders, such as 
multiple sclerosis, is a recent innovation, and the medical effectiveness of such therapy has not been verified by 
scientifically controlled studies. The review has determined that the enrollee does not meet the coverage 
criteria detailed in the NCD. 
 
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 Cala Trio peripheral nerve stimulator device and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Cala Trio peripheral nerve stimulator 
device and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (85060) provided on April 13, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this code is not 
payable. 
 
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 payment for CPT code 85060 is not supported in the medical record. Specifically, code 85060 is 
assigned a PC/TC indicator of 8. This means that payment cannot be made for hospital outpatients or non-
hospital patients. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the services (85060) provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an inpatient 
acute rehabilitation stay. The Plan denied your request. The Plan says the enrollees needs can be met at a 
lower level of care. Skilled therapies at home or skilled nursing facility (SNF) can be approved upon request. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
  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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation (97163) provided on July 30, 
2021. 
 
You asked the Plan to pay for the physical therapy evaluation (97163). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed.  
The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to 
the services of a physician/NPP also must meet all incident-to requirements. 
 
We find that code 97163 is not supported in the record. Specifically, the record shows that this claim was billed 
by a nurse practitioner and the services were rendered by a physical therapist. A nurse practitioner cannot bill 
for the services of a Physical Therapist. Therefore, we decided that the Plan does not have to pay for the 
physical therapy evaluation (97163) provided on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies for the enrollee. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that these items are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not take at least two daily insulin injections. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM and supplies. Our reviewer says 
that a CGM and supplies are not medically reasonable and necessary. The member does have diabetes mellitus.  
 The enrollee is not insulin treated with three or more daily administrations of insulin or on a Medicare-covered 
continuous subcutaneous insulin infusion pump. The enrollees insulin treatment regimen does not require 
frequent adjustment by the enrollee on the basis of blood glucose monitor or CGM testing results. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for a CGM and supplies. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the 
enrollee.