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 December 21, 2021, 
to January 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided medical 
records to support payment. 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 December 21, 2021, to 
January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on September 20, 2022. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and should be 
covered. 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). Therefore, we decided that the Plan does not have to pay for laboratory drug testing 
provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided from 
September 20, 2022, to September 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says prior 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 provider in this case is not a network provider with the Plan. 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 the subsequent nursing facility care (99308) provided from 
September 20, 2022, to September 22, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
 
 
 
 You asked the Plan to pre-approve SNF care. You say that you need more physical therapy because you missed 
out on four days of physical therapy, and they are teaching you things that you need to learn how to do. The 
Plan denied your request. The Plan says your record does not show that you require daily skilled nursing or 
skilled therapy in a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre CGM device. 
 
You asked the Plan to pre-approve a CGM. You say that the requested item is a medical necessity for you. The 
Plan denied your request. The Plan says rules for coverage of CGMs and related supplies have not been met. 
 
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 available documentation does not indicate that you use insulin 
with at least three daily injections. The record shows that the Plan made several attempts to obtain additional documentation without success. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
CGM device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5212). 
 
You asked the Plan to pre-approve the dental service. You say that the partial denture is the only option to 
restore the enrollee's area in their mouth. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the partial lower denture is not covered by the Plan. 
 
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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial lower denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on November 8, 2022, by a 
naturopathic provider. 
 
You asked the Plan to pay for the naturopathic service. You say that your broker advised that this provider was 
in-network. You say that this is the only reason you signed up for this plan. You say that your first visit was 
paid. You also say that nothing has been paid to this provider since then. The Plan denied your request. The 
Plan says prior authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Although the provider is listed as in-network on 
the Plan's website, the Evidence of Coverage clearly states that naturopathic services are not covered. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on November 8, 
2022, by a naturopathic provider.  
 Your complaint about being misled by your broker is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99214), provided on October 5, 2022. 
 
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your 
request. The Plan says that you had other insurance at the time of service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Although the Plan states they 
instructed the provider to bill your primary insurance via phone call, no documentation of this call has been 
provided. Therefore, we decided that the Plan has to pay for the office visit (99214), provided on October 5, 
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 quantitative calcium scoring. 
 
You asked the Plan to pre-approve quantitative calcium scoring. You say that quantitative calcium scoring is 
medically necessary. The Plan denied your request. The Plan says the requested quantitative calcium scoring 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 quantitative calcium scoring. Our reviewer says that the requested quantitative calcium scoring is not medically necessary. Our physician 
reviewer found that you are asymptomatic from a cardiovascular standpoint. Numerous studies have 
demonstrated that coronary artery calcium (CAC) scoring using ultrafast cardiac computed tomography (CT) 
adds predictive value in assessing risk of coronary heart disease (CHD). In one study a score of zero was 
associated with a CHD risk of 1-6%, while a CAC score over 300 was associated with a risk of 13-
26%  (Budoff, 2018). Clinical studies have not, however, shown that CAC scoring adds value in clinical 
management of asymptomatic patients in whom risk factors are targeted. Mamadu in 2014 examined whether 
CAC scoring in asymptomatic adults might have an effect on behavior modification, risk perception, and 
medication adherence. While CAC screening improved medication adherence, the impact of CAC scoring on 
behavioral and lifestyle factors, perception of CHD risk, and psychosocial effects was not statistically 
significant compared with baseline. In summary, current evidence showing that the use of CAC scores in 
clinical management of asymptomatic individuals leads to changes in patient management or in individual risk 
behaviors that improve cardiac outputs outcomes is limited and inconclusive. Overall, there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with 
quantitative evaluation of coronary calcium in guiding optimal management of this patient. As such, CT 
imaging of the heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of your medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of quantitative calcium scoring have not been met. Therefore, we decided that the 
Plan does not have to pre-approve quantitative calcium scoring.
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 was very active and after hip surgery, 
they need additional rehab to return to their prior level of function. The Plan denied your request. The Plan says 
the services the enrollee needs can be provided safely in another setting such as a skilled nursing facility. 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical and 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was in a nursing home and 
could not choose a specific provider. 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). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on November 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance services. 
 
You asked the Plan to pre-approve the ambulance services. You say that the ambulance transport is medically 
necessary. The Plan denied your request. The Plan says ambulance transport, whether via ground or air, to or 
from an outpatient office or facility for a scheduled non-urgent visit is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on April 12, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. 
 
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 physician services. Our reviewer says that the code billed 
is not supported by the records. Our reviewer found the records provided support medical decision making of 
only moderate complexity. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular electrical device (E0770). 
 
You asked the Plan to pre-approve a neuromuscular electrical device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the patient does not have a spinal cord injury. 
 
The Plan follows Medicare rules. Medicare rules say that overage of Neuromuscular Electrical Stimulation 
(NMES) to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle 
is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse 
atrophy. 
 
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 neuromuscular electrical device. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found the member in this case 
has a history of a stroke resulting in spastic hemiplegia. Based on these diagnoses it cannot be said that the 
member's "nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves". Rather, the 
member's issues are directly related to damage of the nerves (from the stroke). 
 
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 neuromuscular electrical device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a neuromuscular electrical device (E0770).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lupus analysis testing provided on May 9, 2022. 
 
You asked the Plan to pay for the lab testing. You say that the testing helps achieve a differential diagnosis. 
The Plan denied your request. The Plan says the screening testing is not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The lab testing in this case was requested for screening purposes. Screening services such as pre-symptomatic 
tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit 
and are not covered. Therefore, we decided that the Plan does not have to pay for the lupus analysis testing 
provided on May 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27760-LT-54 and 99284 billed for date of 
service May 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. 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 27760-
LT-54 is 1. The MAI value for this code is 2. You billed 2 units of this code on the date of service at issue, 
exceeding the MUE. Based on this information, we decided that the Medicare rules for coverage have not been 
met. 
 
The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or 
claim line are denied. We looked at the file and Medicare rules. The file shows that code 99284 was reimbursed 
by the Plan on August 1, 2022. A comparison of the two claims shows that the claim lines exact duplicates. 
There is no evidence presented to support that the billed code was provided twice on the same date. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 27760-LT-54 and 99284 billed 
for date of service May 10, 2022.