Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 15, 2022 to 
January 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 15, 2022 to 
January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on November 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for physician visit. You say that the facility was responsible for obtaining prior 
authorization. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
authorization was not obtained. 
 
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 a physician visit provided on November 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for critical care services (99291) provided on January 13, 2022. 
 
You asked the Plan to pay for the critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that the claim is a duplicate. 
 
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. The plan did not provided any documentation that this service was previously 
paid for this date of service. No claim number of evidence of payment was provided. Therefore, we decided 
that the Plan has to pay for critical care services (99291) provided on January 13, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a computed tomography (CT) scan. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found in the documentation 
there is a notation about nicotine dependence but there is no history of smoking.  Without at least 20 pack years 
of smoking the patient does not qualify for low dose computed tomography (LDCT). 
 
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 computed tomography (CT) scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation provided in the United Mexican 
States on November 6, 2021. 
 
You asked the Plan to pay for air ambulance. You say that the enrollee needed to return to the United States to 
get the proper medical treatment. The Plan denied your request. The Plan says transportation back to the United 
States from another country is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are only covered in limited, specified circumstances. The Plan has a worldwide 
coverage benefit that goes beyond Medicares rules. For that reason, the Plans rules apply. The Plans 
worldwide coverage benefit excludes transportation back to the United States from another country. 
 
We looked at the file and Medicare rules. This service does not meet Medicares rules for coverage of out-of-
country services. Additionally, this transportation back to the United States is excluded from the Plans 
worldwide coverage benefit. Therefore, we decided that the Plan does not have to pay for air ambulance 
transportation provided in the United Mexican States on November 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94060 and 94726 billed for date of service 
August 24, 2022. 
 
You asked the Plan to pay for procedure code(s) 94060 and 94726. You say that this claim was billed correctly. 
The Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 94060 and 94726. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 94060 and 
94726. Based on this information, we decided that Medicare rules for coverage of procedure code 94060 and 
94726 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
94060 and 94726 billed for date of service August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle libre 14 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle libre 14 CGM. You say that the enrollee needs this device to 
track blood glucose level. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle libre 14 CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle libre 14 continuous glucose 
monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthotics (L1971-LT, -RT) provided on November 
21, 2022. 
 
You asked the Plan to pay for the ankle orthotics. You say that the orthotics were medically necessary for the 
enrollee. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support 
the billed supply codes. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Though the file includes an order and proof of 
delivery for the left ankle orthotic, there are no medical records to support the medical necessity of the left ankle orthotic. Additionally, the file includes a proof of delivery and medical records to support the right ankle 
orthotic. The file does not include a valid order for the right ankle orthotic. The file shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the ankle orthotics (L1971-LT, -RT) provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for February 1, 2022. 
 
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 diagnosis code is not supported. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99233 
billed for February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) and portable oxygen 
system (E0431) provided on November 19, 2022. 
 
You asked the Plan to pay for the oxygen concentrator and portable oxygen system. You say that the home 
oxygen therapy is medically necessary. The Plan denied your request. The Plan says the home oxygen therapy 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen concentrator and portable 
oxygen system. Our reviewer says that the home oxygen therapy is not medically necessary. Our physician 
reviewer found in this case, the records do not document an arterial PO2 at or below 55 mm Hg, or an arterial 
oxygen saturation at or below 88%, taken at rest, breathing room air; or, an arterial PO2 at or below 55 mm Hg, 
or an arterial oxygen saturation at or below 88%, taken during sleep or an arterial PO2 at or below 55 mm Hg 
or an arterial oxygen saturation at or below 88%, taken during exercise, as required by Medicare criteria. 
 
Records report the enrollee's "Baseline O2 requirement is 2L as needed." As stated in the LCD, "Emergency or 
stand-by oxygen systems for beneficiaries who are not regularly using oxygen will be denied as not reasonable 
and necessary since they are precautionary and not therapeutic in nature." 
 
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 oxygen concentrator and portable oxygen system have not been met. 
Therefore, we decided that the Plan does not have to pay for the oxygen concentrator (E1390) and portable 
oxygen system (E0431) provided on November 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 17, 
2022, to March 21, 2022, and to pay for pontics (D6245) and retainer crown (D6740) on August 2, 2022.  
 
You asked the Plan to waive the copayment for an inpatient hospital stay from March 17, 2022, to March 21, 
2022, and to pay for pontics (D6245) and retainer crown (D6740). the dental services. You say that you would 
like the Plan to pay for all of this. The Plan denied your request. The Plan says these claims have been 
processed 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 $265 
copayment per day for days 1-4 for inpatient hospital services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your dental allowance was exhausted on August 2, 2022. Therefore, we decided that the Plan does not 
have to pay for pontics (D6245) and retainer crown (D6740) on August 2, 2022.   
 
You have been asked to pay a $265 copayment per day for days 1-4 for inpatient hospital services. This 
item/service falls within the inpatient hospital 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 inpatient hospital services provided on March 17, 2022, to March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says insufficient 
information was provided to approve this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI benefits have been met. In this case medical records were needed to review this request. The Plan requested this information, but it was not 
received. Without this information we are unable to verify whether criteria are met for coverage of SSBCI 
benefits. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ustekinumab (J3357) injections provided on November 30, 
2022. 
 
You asked the Plan to pay for Ustekinumab. You say that this injection was medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 pay for Ustekinumab (J3357) injections 
provided on November 30, 2022.  
 
Benefits for Ustekinumab 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing home care provided on April 7, 2022. 
 
You asked the Plan to pay for the subsequent nursing home care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the member was enrolled in hospice on this date of 
service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing home care provided on April 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 94640 billed for date of service November 6, 2022. 
 
You asked the Plan to pay for code 94640. You say that this is a covered service and was medically necessary. 
The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. 
 In this case, the code in dispute (code 94640) has a status indicator of Q1, meaning that it is a STV-packaged 
service. This code was billed on the same claim as Revenue Code 450, which has a status indicator of V. This 
means that separate payment for code 94640 cannot be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 94640 have not been met. Therefore, we decided that the Plan does not have to pay for code 
94640 billed for date of service November 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine services 
(99397) and screening Papanicolaou (PAP) smear (Q0091) provided October 18, 2022. 
 
You asked the Plan to pay for the office visit. You say that you was informed the doctor no longer accepts 
Medicare patients in 2022 but failed to inform you at the time you made the appointment or when services were 
rendered. The Plan denied your request. The Plan says the services was received from a provider who chose not 
to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
periodic comprehensive preventive medicine services (99397) and screening Papanicolaou (PAP) smear 
(Q0091) provided October 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say in their current condition, the enrollee cannot 
be adequately cared for at a skilled nursing facility (SNF) or any other lower level of care. The Plan denied 
your request. The Plan says the enrollee does not meet guidelines for admission to an LTACH. 
 
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 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 Plan. The 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 LTACH services.