Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 24, 2022. 
 
You asked the Plan to pre-approve SNF care after March 24, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 after March 24, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does 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 SNF care after March 24, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-
hour facility (99053) provided on September 3, 2021. 
 
You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility. You 
say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says CPT code 99053 has a status indicator of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99053 is not supported in the record. Specifically, CPT code 99053 has a status 
indicator of B which means that payment for this service is always included in the payment for another service 
or procedure. Based on this information, we decided that Medicare rules for coverage of the services provided 
between 10:00 PM and 8:00 AM at 24-hour facility have not been met.  Therefore, we decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 
AM at 24-hour facility (99053) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that this should be covered to ensure adequate pain 
control. The Plan denied your request. The Plan says the enrollee's pain relief from prior injection has not 
lasted long enough. 
 
The Plan follows Medicare rules. Medicare rules say that ESIs may be repeated when there has been 50% pain 
relief for at least three months.  
 
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 ESI. Our reviewer says that the 
requested ESI is not considered medically necessary at this time. Our physician reviewer found the enrollee is a 
78-year-old female with a history of low back pain due to lumbar degenerative disc disease and lumbar spinal 
stenosis with neurogenic claudication. She is currently participating in a physical therapy program, ambulating 
with a walker, and taking Advil and Gabapentin for pain. She received over 70% pain relief from an ESI 
performed on February 8, 2022. The record does not show that this pain relief has lasted for three months. As 
such, a repeat ESI is not covered at this time. 
 
 
 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services to be 
provided by an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee has a clear diagnosis and 
treatment plan for a five week stay in the LTAC setting. You also say you would like the Plan to approve this 
admission at the in-network rate. The Plan denied your request. The Plan says since the member has point-of-
service benefits and other options are available for in-network acute care facilities that provide the same level 
of care he continues to require, the request for an in-network exception is not medically necessary. The 
authorization for LTAC admission remains approved at the enrollee's point-of-service benefit. 
 
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 facility in this case is not a network facility with the Plan. The Plan has network facilities 
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 
long term acute care hospital (LTACH) services to be provided by an out-of-network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided at 24-hour facility, in addition to basic 
service (99053) provided on July 24, 2021. 
 
You asked the Plan to pay for the services provided at 24-hour facility, in addition to basic service (99053). 
You say that you have appropriately applied the level of service in compliance with the guidelines. You say 
that the documentation supports the level billed and the claim should be reprocessed appropriately. The Plan 
denied your request. The Plan says CPT code 99285 has been overturned. The Plan also says CPT code 99053 
remains denied as bundled services are not eligible for separate payment. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B. This means that CPT code 99053 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the services provided at 24-hour facility, in 
addition to basic service (99053) have not been met. Therefore, we decided that the Plan does not have to pay 
for the services provided at 24-hour facility, in addition to basic service (99053) provided on July 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 11, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 93010 
is a column II code to column I code 12001. 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 imaging services provided to the enrollee on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided to the enrollee on March 
29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed supply codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that DME supplies must be provided with a proof of delivery. 
 
 
 We find that CPT code is not supported in the medical record. Specifically, the required documentation 
pertaining to the proof of delivery of these supplies was not provided. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for the wound care supplies provided to the enrollee on March 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided at 24-hour facility, in addition to basic 
service (99053) provided on July 12, 2021. 
 
You asked the Plan to pay for the services provided at 24-hour facility, in addition to basic service (99053). 
You say that the requested medical records are enclosed, and the claim should be reconsidered for payment. 
The Plan denied your request. The Plan says bundled services are not eligible for separate payment. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
  We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B. This means that CPT code 99053 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the services provided at 24-hour facility, in 
addition to basic service (99053) have not been met. Therefore, we decided that the Plan does not have to pay 
for the services provided at 24-hour facility, in addition to basic service (99053) provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aflibercept 1MG injection (CPT code J0178). 
 
You asked the Plan to pre-approve the medication. You say that this could help prevent you from going blind. 
The Plan denied your request. The Plan says the drug your doctor requested is a non-preferred product. The 
Plan states they only cover this medicine if you cannot take or have side effects from the preferred medication 
Avastin for your condition. 
 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 the medication. Our physician reviewer 
found you have not tried and failed the required drug(s). There is no documentation provided indicating that the 
plans required drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aflibercept 1MG injection (CPT code J0178).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya Soln Pref Syr 100MG/ML. 
 
You asked the Plan to pre-approve the medication. You say that this is an important and necessary part of the 
enrollee's treatment plan. The Plan denied your request. The Plan says they do not have a record from the 
enrollee's prescriber that shows they have tried one of the preferred drugs Remicade or Avsola and it has not 
worked, or that the enrollee has medical reasons that prevent them from one of them. 
 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 the medication. Our physician reviewer 
found the provided records did not clearly show that the enrollee has tried and failed either Remicade or 
Avsola. Based on the above medications each being in the same class and with similar effectiveness and safety 
profiles for the enrollee's condition, it is not likely that Remicde or Avsola would be less effective or have more 
adverse effects compared to the requested Ilumya around the 12-week mark based on current comparative 
studies. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya Soln Pref Syr 100MG/ML.  
 
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses provided on December 2, 2021. 
  You asked the Plan to pay for the progressive lenses. You say that you were told you need the glasses after 
surgery and that they would be covered. The Plan denied your request. The Plan says only standard glasses or 
contacts are covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan only covers standard glasses or contacts after each cataract surgery. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the progressive lenses have not been met. Specifically, upgraded lenses are not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for the progressive lenses provided on December 2, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AFO and diabetic shoes with inserts (CPT code(s): 
L2780, L2630, L1990, L2220) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the items. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is an in-network provider that can provide the items. 
 
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 AFO and diabetic shoes with inserts (CPT 
code(s): L2780, L2630, L1990, L2220) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on May 6, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation submitted on appeal indicates the cardiovascular genetic screening 
panel was initiated by the laboratory and not by the enrollee's treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of cardiac risk assessment genetic 
screening testing provided to the enrollee on May 6, 2021. have been met. The provider has not provided any 
medical records, laboratory results, or any proof to show that this service was ordered by the enrollee's treating 
physician and was medically reasonable or necessary.. Therefore, we decided that the Plan does not have to pay 
for cardiac risk assessment genetic screening testing provided to the enrollee on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the automatic external defibrillator (CPT code K0606) 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network DME. You say that this provider provides items that the 
competitor does not provide. The Plan denied your request. The Plan says there was no medically necessary 
information provided as to why this enrollee was seeking out-of-network coverage. 
 
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 the automatic external defibrillator (CPT code K0606) to be 
provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor 
(CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you would like reconsideration because you are 
visually impaired and the meter would be helpful. The Plan denied your request. The Plan says you do not meet 
criteria for coverage. 
 
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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre 
Continuous Glucose Monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Contour Next EZ blood glucose monitor and Contour 
Next test strips for the enrollee. 
 
You asked the Plan to pre-approve a Contour Next EZ blood glucose monitor and Contour Next test strips. You 
say that the patient is elderly and comfortable using and reading the Contour meter. The Plan denied your 
request. The Plan says that there is no information the enrollee has tried and failed the preferred products. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation documenting why the 
enrollee requires this specific brand of blood glucose meter and test strips. Without this, medical necessity 
cannot be established. Therefore, we decided that the Plan does not have to pre-approve a Contour Next EZ 
blood glucose monitor and Contour Next test strips for the enrollee.