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

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
August 23, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. The file 
shows that the submitted proof of delivery does not match the billed date of service. 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 the continuous glucose monitor (CGM) supplies rendered on August 23, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 6, 2022, to  
July 12, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 6, 2022, to July 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supplies rendered on March 8, 2022, 
to March 10, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 the parenteral nutrition supplies rendered on March 8, 2022, 
to March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis rendered on July 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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the elbow orthosis rendered on July 1, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 additional physical therapy visits 
 
You asked the Plan to pre-approve the therapy services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the record does not indicate the enrollees objective progress with 
physical therapy, Therefore, 11 visits of additional therapy cannot be considered medically necessary. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 11 additional physical therapy visits
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 you just had heart surgery and the rehabilitation is 
beneficial to your recovery efforts. The Plan denied your request. The Plan says you do not meet the Medicare 
criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99292 provided on March 19, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service billed is not supported. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the documentation notes 
spending 45 minutes on critical care time. This means that additional 30 minutes is not supported. Based on 
this information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services coded 99292 provided on 
March 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of procedure code 99291 billed for date of 
service September 9, 2022. 
 
You asked the Plan to pay for a second unit of procedure code 99291. You say that the enrollee has multiple 
exams on this date The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, the first of which was previously paid, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of a second unit of procedure code 99291 have not been met. Therefore, we 
decided that the Plan does not have to pay for a second unit of procedure code 99291 billed for date of service 
September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on August 04, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that it is the facilitys responsibility to obtain 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Please note that the facility/surgeon is also not a Plan network provider. Therefore, 
we decided that the Plan does not have to pay for the anesthesia services provided on August 04, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (70145) provided on May 23, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 22, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray (70145) 
provided on May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided July 6, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was 
prescribed by the doctor and was issues to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided July 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy to be provided by the requested out-of-network provider. 
The Plan denied your request. The Plan says you must receive your care from a network provider. In most 
cases, care you receive from an out-of-network provider will not be covered. Here are three exceptions: The 
plan covers emergency or urgently needed services that you get from an out-of-network provider. If you need 
medical care that Medicare requires our plan to cover and the providers in our network cannot provide this 
care, you can get this care from an out-of-network provider. A prior authorization is required if you are seeking 
non-emergency out-of-network care. In this situation, you will pay the same as you would pay if you got the 
care from a network provider. The Plan covers kidney dialysis services that you get at a Medicare-certified 
dialysis facility when you are temporarily outside the Plans service area. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy to be provided by the requested out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 8, 2022, to 
August 10, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 8, 2022. The NOA was not received by the Plan until March 23, 
2017. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from August 8, 2022, to August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050), measurement of vitamin D 
25 hydroxy (82306), assay of folic acid serum (82746), and measurement of cyanocobalamin (vitamin B-12) 
(82607) provided on April 4, 2022. 
 
You asked the Plan to pay for the general health panel or measurement of vitamin D, folic acid and B-12. You 
say that this testing was medically necessary. The Plan denied your request. The Plan says these services are 
not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. The rules also explicitly say that screening tests, with the exception of the few tests listed in the 
Medicare rules section, are not covered. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. The testing for vitamin D, folic acid and vitamin B12 was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the general health panel (80050), measurement of vitamin D 25 hydroxy (82306), 
assay of folic acid serum (82746), and measurement of cyanocobalamin (vitamin B-12) (82607) provided on 
April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enrollment in the Special Supplemental Benefits for the 
Chronically Ill (SSBCI) benefit. 
 
You asked the Plan to pre-approve SSBCI benefit. You say that you need this benefit. The Plan denied your 
request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of the 
eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve enrollment in the Special Supplemental Benefits for the Chronically Ill (SSBCI) benefit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift, hydraulic or mechanical, includes any seat, 
sling, straps or pads (E0630) provided September 2, 2022. 
 
You asked the Plan to pay for the patient lift. You say that you would like to have the prior authorization denial 
over-ridden, and the claim reviewed for payment with the attached supporting documentation which shows the 
supplies were medically necessary and provided under a physician's prescription. The Plan denied your request. 
The Plan says the capped rental period (13 months) for this item has been exceeded. 
 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 find that CPT code E0630 is not supported in the medical record. Specifically, the records 
show that the patient lift (E0630) was delivered on July 1, 2021. The capped rental period (13 months) for this 
item has been exceeded. Once the 13th month of rental ends, the supplier must transfer ownership of the 
equipment to the enrollee. Based on this information, we decided that Medicare rules for coverage of the 
patient lift have not been met. Therefore, we decided that the Plan does not have to pay for the patient lift, 
hydraulic or mechanical, includes any seat, sling, straps or pads (E0630) provided September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for procedures on eye provided on 
August 17, 2022. 
 
You asked the Plan to pay for anesthesia for procedures on eye. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 anesthesia for procedures on eye provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
pneumatic appliance (E0673) provided April 18, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are not 
contracted with the facility or the prescribing physician and do not receive payment from either provider. The 
Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and segmental pneumatic appliance (E0673) provided April 
18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 15, 2020. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until June 15, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on December 15, 2020.