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

 
We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on October 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 that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the services are not covered by the enrollee's plan; however, 
the Plan has not provided any documentation or further explanation as to why the services are not covered. The 
Plan has not provided any binding Medicare rules to support that the services are not covered. Therefore, we 
decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on October 1, 
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: Favorable

 
We decided that the Plan has to pay for the supply allowance for therapeutic continuous glucose monitor coded 
K0553 provided on June 30, 2022. 
 
You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says that the documentation 
submitted did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has denied this code due to the documentation submitted did not 
sufficiently support the billed supply code. The documentation included medical records and a prescription for 
the items rendered. No detailed explanation on why the billed supply code is not supported was provided. No 
other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the 
Plan has to pay for the supply allowance for therapeutic continuous glucose monitor coded K0553 provided on 
June 30, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services, initial assessment, face-
to-face, 15 minutes per unit (97802) provided July 14, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says procedure code 
97803 has not met the associated diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pay for medical nutrition therapy services, initial assessment, face-to-face, 15 minutes per unit 
(97802) provided July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the extracapsular cataract removal with 
insertion of intraocular lens prosthesis (66984) provided October 18, 2022, to November 18, 2022. 
 
You asked the Plan to waive the copayment for the surgical services. You say that you are appealing the denial 
of billing from your bilateral cataract surgery. You selected the Toric lens implants after discussion with your 
doctor. 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 $250 
copay for outpatient surgery services.  
 
You have been asked to pay $500 ($250 copay + $250 copay) copay for the surgical services. The provided 
Explanation of Benefits dated October 31, 2022, and November 22, 2022, also shows that the provider may 
only bill for $250 for both dates of service. This item/service falls within the Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the extracapsular cataract removal with insertion of intraocular lens 
prosthesis (66984) provided October 18, 2022, to November 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 14, 2022, by an 
out-of-network (OON) provider. 
 
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 were rendered by a non-contracted provider without 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 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 the laboratory services provided on March 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 22, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. 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 July 22, 2022, to August 
30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Aer. 
 
You asked the Plan to pre-approve these services. You say that the drug is needed for emphysema and acute 
pulmonary embolism. The Plan denied your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Aer.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine culture, bacterial (87086) provided on September 
14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that you are enclosing the medical records related 
to these services and requesting payment for services that have been provided. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered. 
 
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 the urine culture, bacterial (87086) provided on 
September 14, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical, multiple post collar, occipital/mandibular 
supports provided on October 25, 2022. 
 
You asked the Plan to pay for the cervical, multiple post collar, occipital/mandibular supports. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the documentation submitted 
did not sufficiently support the billed code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The documentation submitted did not sufficiently support the billed supply code. The medical 
records do not support the need for the enrollees neck to be supported. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the cervical, multiple post collar, occipital/mandibular supports provided on October 
25, 2022.
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 are not strong enough at this point and would 
like to gain some of your strength back before being released home. The Plan denied your request. The Plan 
says you are currently at your baseline level of function and daily physical and occupational therapy is not 
medically necessary, your needs your needs can be met with intermittent therapy three to four times per week 
and non-skilled custodial care.  
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 the clinical documentation shows that you had a functional/clinical status change; 
thus, skilled nursing/therapy would be medically appropriate. However, there is no recommendation for or 
documentation to show that you require daily skilled services on an inpatient basis in a SNF. In addition, your 
past level of function is not completely specified. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 99222. You say that these services were provided in good faith 
and should be paid. The Plan denied your request. The Plan says payment for code 99222 is bundled into 
payment for code 99497. 
 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 99222 
is a column II code to column I code 99497. 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 99222 billed for date of service August 3, 2022.
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 are becoming more dependent on help. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
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 you do not require an acute rehabilitation hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including  
 either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. You can receive 
further services 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided during arthroplasty 
services provided on April 20, 2022. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided during arthroplasty services provided on April 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided on  
September 24, 2022. 
 
You asked the Plan to pay for the paramedic intercept services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that provider does not have a contract with the volunteer ambulance company that 
provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services provided on September 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01992 billed for date of service December 
15, 2021. 
 
You asked the Plan to pay for procedure code 01992. You say that this claim should be reprocessed. The Plan 
denied your request. The Plan says payment for code 01992 is bundled into payment for code 62322. 
 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 01992 
is a column II code to column I code 62322. 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 01992 billed for date of service December 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radioembolization treatment (79445). 
 
You asked the Plan to pre-approve radioembolization. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 radioembolization. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there are no records demonstrating that standard systemic therapy was either given or even 
considered prior to the requested services. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radioembolization have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radioembolization treatment (79445).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0155 provided on November 2, 2022. 
 
You asked the Plan to pay for procedure code E0155. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says there is a paid claim for a walker coded as 
E0135 with a date of service of November 1, 2022. Under Medicare rules the request for separate payment for 
wheel attachments for a walker is not a covered benefit because the date of service is within one month of the 
initial non-wheeled walker. 
 
The Plan must follow Medicare rules. The rules say code E0155 cannot be used for wheels provided at the time 
of, or within one month of, the initial issue of a non-wheeled walker. 
 
We looked at the file and Medicare rules. In this case, the file shows there is a paid claim for a walker coded as 
E0135 with a date of service of November 1, 2022. Under Medicare rules the request for separate payment for 
wheel attachments for a walker is not a covered benefit because the date of service is within one month of the 
initial non-wheeled walker. Therefore, we decided that the Plan does not have to pay for procedure code E0155 
provided on November 2, 2022.