Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the enrollee has needle 
phobia, a condition called Hemoglobinopathy. The enrollee cannot use Hemoglobin A1C test.  The best way to 
monitor the enrollees diabetes is with evaluating glucose trends, this would require multiple daily finger sticks, 
which are too burdensome for the enrollee due to the pain. The Plan denied your request. The Plan says the 
enrollee does not meet prior authorization 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, 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 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 2 CGM sensor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on March 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. 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 domiciliary services provided on March 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health (HH) services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve HH services. You say that you need home health services care. The Plan 
denied your request. The Plan says review of the submitted medical record did not indicate a need for home 
care services. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 HH services. Our physician reviewer found based on the limited 
documentation provided, it is my opinion that the health plans denial should be upheld. The type of HH 
services being requested is unclear. The hospital records do not note that HH services were recommended or 
necessary. No nursing or therapy records have been submitted for review. No HH records have been submitted 
for review. As such, the records fail to establish that the enrollee had a HH need, or that such a need was 
emergent or urgent and, therefore, should be provided out-of-area/out-of-network. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HH services have not been met.  
 
The Plan has network providers available who can provide the HH services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve HH services. Therefore, we decided that the Plan does not 
have to pre-approve HH services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collagen based wound filler (A6010) and hydrocolloid 
dressing, wound cover, sterile (A6237) provided December 27, 2021. 
 
You asked the Plan to pay for the wound supplies. You say that the enrollee was admitted to the center but was 
not placed under SNF status with Medicare. Therefore, the wound care supplies are payable. The Plan denied 
your request. The Plan says payment for this service is included in Part A SNF payment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound supplies was used in a SNF or hospital. Therefore, we decided that the Plan does 
not have to pay for the collagen based wound filler (A6010) and hydrocolloid dressing, wound cover, sterile 
(A6237) provided December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the physical therapist advised that 
there is no way you can hold the enrollee and stabilize the bed to support him. The enrollee has not gotten any 
better and there is a fear that he will be stuck in the bed. The Plan denied your request. The Plan says the 
requested bed is not a covered item; the height adjustment feature is a convenience feature. 
 
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 (E0265).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient laboratory testing, including a magnesium assay 
(83735), provided on January 27, 2022. 
 
You asked the Plan to pay for outpatient laboratory testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because payment for the services at issue is included in the payment for another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules list the diagnosis codes that support 
medical necessity for a magnesium assay. 
 
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 outpatient laboratory testing. Our reviewer says that the 
services at issue do not meet criteria for payment. Our reviewer found that outpatient laboratory tests are generally packaged as ancillary services and do not receive separate payment. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient laboratory testing have not been met. Furthermore, we found that the 
billed diagnosis codes are not listed as codes that support medical necessity for a magnesium assay. Therefore, 
we decided that the Plan does not have to pay for outpatient laboratory testing, including a magnesium assay 
(83735), provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on January 6, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. 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 domiciliary services provided on January 6, 2022, 
by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service January 11, 
2022. 
 
You asked the Plan to pay for procedure code 93971. You say that the services provided o this date of service 
were rendered appropriately in response to the enrollee's medical condition. Please reprocess the previously denied claim. The Plan denied your request. The Plan says payment for code 93971 is bundled into payment for 
code 93970. 
 
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, we have confirmed that code 93971 
is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93971 billed for date of service January 11, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the routine physical exam billed with procedure code 99397 you 
received on April 20, 2022, from a contract provider. 
 
You asked the Plan to pay for the routine physical exam. You say that you believe this service was billed using 
an incorrect code. The Plan denied your request. The Plan says that this is not a covered service. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided these services by a contract provider. The file does not show that the Plan provided notice 
that the routine physical exam would not be covered. Your Evidence of Coverage does not explicitly state that 
routine physicals are not covered.  Further, there is no evidence that this contract provider told you that this 
service would not be covered. Lastly, by the Plan's own admission, the provider may have been unaware that 
your plan didn't cover this service.  It is the to responsibility of a contract provider to know what services are 
covered and which ones are not.  By providing you with this service and not advising you that it is not a 
covered benefit, under Medicare rules, this means the routine physical exam is considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for the routine physical exam billed with procedure code 
99397 you received on April 20, 2022, from a contract provider.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says that rules for SNF care have not been met. 
 
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 physician reviewer 
found the clinical documentation shows that the enrollee has multiple medical issues present which would 
require the supervision of a skilled nurse. The enrollee has functional impairments and requires skilled 
physical, occupational, and speech therapy. The Plan has argued that the evaluating therapists do not 
recommend daily skilled therapy; however, newer notes by the physical and occupational therapists do 
recommend daily skilled services. The records support that this is reasonable and, as a practical matter, the 
enrollee requires daily skilled services to be provided on an inpatient basis in the 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 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 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimzia. 
 
You asked the Plan to pre-approve Cimzia. 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. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Cimzia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation provided 
indicating that the plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cimzia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Cimzia.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for ophthalmological services, medical examination and evaluation 
provided on March 21, 2022. 
 
You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied 
your request. The Plan says that we have paid the maximum amount covered by your plan for this service. 
 
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 documentation to support how the 
maximum amount was covered by the Plan. Therefore, we decided that the Plan has to pay for 
ophthalmological services, medical examination and evaluation provided on March 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 test kits you purchased on January 19, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you submitted all of the 
documentation to get reimbursed and it had been advertised that if you purchased these tests they would be 
reimbursed. The Plan denied your request. The Plan says at-home COVID-19 test kits were not covered under 
your Plan until February 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans may cover at-home 
COVID-19 test kits as a supplemental benefit starting January 15, 2022, or prior depending on the specific 
benefits offered by the Plan. You can find this information on the Centers for Medicare and Medicaid Services 
website at  https://www.cms.gov/how-to-get-your-at-home-OTC-COVID-19-test-for-free. In this case, your 
Plan did not offer a supplemental benefit for coverage of at-home COVID-19 tests until February 1, 2022. You 
purchased these test kits prior to eligibility for this benefit. Based on this information, we decided that 
Medicare rules for coverage of the at-home COVID-19 test kits have not been met. Therefore, we decided that 
the Plan does not have to pay for at-home COVID-19 test kits you purchased on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 tests you purchased on December 28, 
2021. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that these tests should be covered because 
it was only a month before the Plan started covering them.  You said that you purchased these tests during the 
height of the Omicron variant and because you are a Type II diabetic, catching COVID-19 could be very 
serious for you. The Plan denied your request. The Plan says at-home COVID-19 tests were not covered until 
after February 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans may cover at-home 
COVID-19 tests as a supplemental benefit starting January 15, 2022, or prior depending on the specific benefits 
offered by the Plan. In this case, your Plan didn't offer supplemental coverage of at-home COVID-19 tests until 
February 1, 2022.  You purchased the tests in question prior to this date of eligibility. Based on this 
information, we decided that Medicare rules for coverage of the at-home COVID-19 tests have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pay for at-home COVID-19 tests you purchased on 
December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
January 20, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically 
necessary services in good faith. The Plan denied your request. The Plan says non-emergent, non-urgent 
services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 1, 
2022. 
 
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 records do not support the services 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 the denied codes is: 
 
CPT 25320: 
 
Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) 
(includes synovectomy, capsulotomy and open reduction) for carpal instability 
 
CPT 26449: 
 
Tenolysis, complex, extensor tendon, finger, including forearm, each tendon 
 
CPT 64708:  
Neuroplasty, major peripheral nerve, arm or leg, open; other than specified 
 
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 that the documentation says that 
"Neuroplasty was then performed of the sensory radial nerve. Litter scissors, 11 blade, fine pickups, and 69 
blade were used for the tenolysis. There was improvement of the nerve noted." The documentation is 
insufficient to support open neuroplasty of a major peripheral nerve of the arm or leg, and CPT 64708 is not 
supported. Additionally, the documentation does not support that CPT 25320 or CPT 26449 was rendered in 
this case. 
 
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 surgical services provided to the enrollee on February 1, 2022.