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

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve 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. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47379 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 47379. You say that you do not believe this code should be 
bundled. The Plan denied your request. The Plan says payment for code 47379 is bundled into payment for 
code 76998-26. 
 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 47379 
is a column II code to column I code 76998-26. 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 47379 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you would like to continue receiving care from the 
out-of-network provider. The Plan denied your request. The Plan says the service can be provided by an in-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service November 
13, 2021. 
 
You asked the Plan to pay for procedure code 93976. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 93976 is bundled into payment for code 93975. 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 93976 
is a column II code to column I code 93975. 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 93976 billed for date of service November 13, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage for the continuous airway pressure 
(CPAP) device (E0601). 
 
You asked the Plan to pre-approve the CPAP device. You say that you have been taking care of your mother 
and have not been using your machine but would like the Plan to continue covering the CPAP machine. The 
Plan denied your request. The Plan says the request is not medically necessary as the enrollee has not been 
using the device regularly. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the CPAP device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records do not document that the enrollees treating practitioner has 
conducted a recent clinical re-evaluation beyond the first three months of CPAP therapy and documented that 
the enrollee is compliant with and benefiting from the CPAP therapy as required by the LCD. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued coverage for the continuous airway pressure (CPAP) device (E0601).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81455) billed for date of service April 15, 2022. 
 
You asked the Plan to pay for genetic testing. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says that the date of service for a clinical laboratory test or the 
technical component of physician pathology service must be the date the specimen was collected. This claim 
was incorrectly billed with a date of service of April 15, 2022, when the specimen was collected on February 
16, 2022. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also 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 acknowledged nor addressed the exceptions to the 
rule applied in this case. The testing in this case was performed on live tumor tissue which was collected during 
a biopsy procedure performed in an outpatient hospital setting. It is necessary and appropriate for a biopsy to be 
performed in this setting, and it does not appear that the results of this test impacted the enrollee's hospital care 
at the time of specimen collection. This means that an exception is likely met in this case, and the correct date 
of service to report would be the date the test was performed: April 15, 2022. Therefore, we decided that the 
Plan has to pay for genetic testing (81455) billed for date of service April 15, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service June 16, 
2022. 
 
You asked the Plan to pay for procedure code 94761. You say that this service is supported as billed. The Plan 
denied your request. The Plan says procedure code 94761 is considered bundled and not separately payable, as 
this code has a status indicator of T and was billed with another physician service which has been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 94761 has a status indicator of T on the Physician Fee Schedule. We also find that 
this service was billed with code 99205, which is a physician service. This means that procedure code 94761 is 
not separately payable in this case. Based on this information, we decided that Medicare rules for coverage of 
procedure code 94761 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 94761 billed for date of service June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requirements for coverage 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 documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 6, 1011, 
to January 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these services could have been provided at a lower 
level of care. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the above presentation and emergency department documentation, the 
enrollee was not unstable, and had COVID with side effect from Reglan and was not expected to require 
hospital services that would likely cross 2 midnights. Treatment could have been completed at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on January 6, 1011, to January 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Gel-One. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has bilateral knee pain related to osteoarthritis, diagnosis confirmed with imaging studies. 
The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried 
and failed Durolane, Monovisc or Synvisc-One. The documentation does not support an indication that 
Durolane, Monovisc or Synvisc-One 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 Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation care provided from 
May 29, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for the hospital observation care. You say that you do not know 
why you were charged for office visits when you were admitted to the hospital. The Plan denied your request. 
The Plan says this cost sharing was charged 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 $25 
copayment for medically necessary medical care or surgery services furnished in a physician's office, certified 
ambulatory surgical center, hospital outpatient department, or any other location (specialist).  
 
The records show that you stayed in the hospital under outpatient observation care. The claims were also billed 
by the providers directly, therefore, you have been asked to pay a $25 copayment for each day of hospital observation care. This item/service falls within the medically necessary medical care or surgery services 
furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any 
other location (specialist) benefit category. The total for the three days is $75. 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 hospital observation care provided from May 29, 2022, to May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet all the 
requirements for admission. 
 
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 the enrollee was admitted on May 15, 2022, after an abnormal stress test. On May 26, 
2022, the enrollee underwent a coronary artery bypass graft and tricuspid valve repair. As of October 16, 2022, 
the enrollee is alternating a tracheostomy collar and ventilator. The enrollee is on total parenteral nutrition and 
hemodialysis. The enrollee also has a sacral ulcer receiving debridement treatments, and an abdominal wound 
that will need future debridement. The enrollee is receiving appropriate care at the present setting. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the chest (71250). 
 
You asked the Plan to pre-approve a CT of the chest. The Plan denied your request. The Plan says that all 
record entries point to the thoracic spine as the source of the left chest wall pain, and doing both scans would 
not make sense. 
 
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 CT of the chest. Our reviewer says 
that a CT of the chest is reasonable and necessary. Our physician reviewer found the enrollee's symptoms may 
be related to thoracic spine neural compromise however also could relate to hairline fractures of the anterior 
ribs or costochondritis. Our reviewer also found that the persistence of anterior chest wall symptoms would 
thus not be evaluated by a magnetic resonance imaging of the thoracic spine and the requested CT would 
complete the workup. 
 
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 CT of the chest have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) of the chest (71250).  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 11, 
2022, to May 10, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the continued stay was not 
medically necessary. The Plan also says that the enrollee had returned to near their baseline level of function no 
longer requiring skilled therapy and did not have skilled nursing needs.  
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 pay for the 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 the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from April 11, 2022, to May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a digital hearing aid provided from June 14, 2022, to 
July 8, 2022. 
 
You asked the Plan to pay more for a digital hearing aid. You say that you received a receipt stating that you 
had a zero copayment. You also say that you called the provider the next day and were told that the service had 
been coded incorrectly, and you needed to finance payments in the amount of $590. The Plan denied your 
request. The Plan says your plan benefit pays up to $3,000 every three years for hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to $3,000 once every three years.  
 
We looked at the file, and the Plan's rules. The Plan says that they pay for hearing aids up to $3,000 once every 
three years. You are responsible for any cost more than that. We have confirmed the Plan has paid $3,000, 
which fulfills the hearing aid benefit. Based on this information, we decided that the Plan's rules for coverage 
of a digital hearing aid have not been met. Therefore, we decided that the Plan does not have to pay more for a 
digital hearing aid provided from June 14, 2022, to July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 23, 2022, billed 
with code 0037U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the enrollee meets all the requirements for 
coverage. The Plan denied your request. The Plan says the unique test identifier is missing from the claim form. 
 
The Plan must follow Medicare rules. The rules say that claims must include the unique test identifier assigned from 
the DEXTM in order to be paid. 
 
We looked at the file and Medicare rules. The claim was not billed with the unique test identifier, as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 23, 2022, 
billed with code 0037U.