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. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has developed an altered mental status, 
slurred speech and has been unable to work with physical and occupational therapies. You say that the SNF is 
medically necessary. The Plan denied your request. The Plan says the SNF care is not medically necessary, and 
the enrollee's needs can be met in an outpatient 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 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 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart implantable pulse generator. 
 
You asked the Plan to pre-approve Optimizer Smart implantable pulse generator. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 Optimizer Smart implantable pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, 
cardiac contractility modulation (CCM) remains the subject of multiple studies examining long-term efficacy, 
as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically 
rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, a 
CCM system is not considered to be medically necessary in this 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 Optimizer Smart implantable pulse generator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Optimizer Smart implantable pulse generator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology, in situ hybridization (eg, FISH), urinary 
tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (88120) provided 
June 10, 2022. 
 You asked the Plan to pay for the cytopathology. You say that this testing should be covered. The Plan denied 
your request. The Plan says this testing is not covered for screening purposes. 
 
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 test at issue in this appeal, the cytopathology, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 
molecular probes, each specimen; manual (88120) provided June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that the enrollee does not want to be on insulin but it is 
important to check blood sugar several times per day. The Plan denied your request. The Plan says the enrollee 
does not use injectable insulin at least 3 times per day. 
 
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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services provided on July 26, 2022, to August 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON infusion services. You say that you did not know your provider was not in-
network. The Plan denied your request. The Plan says these services were not authorized. 
 
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 infusion services provided on July 26, 2022, to 
August 24, 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 February 4, 2022, to 
March 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted a NOA, so this 
claim should be paid. 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 February 4, 2022, to 
March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental pneumatic appliances (E0673) provided July 
1, 2022. 
 
You asked the Plan to pay for the pneumatic appliances. You say that the enrollee is given the VenaPro or it is 
delivered to their house after the surgery. The POS code for this product should, therefore, rightfully be a 12. 
Some would consider the use of 24 POS code in this situation is fraudulent. The Plan denied your request. The 
Plan says since the place of service (POS) is an ambulatory surgical center (24)m the segmental gradient 
pressure pneumatic appliance, half leg (E0673 RT/LT) is not covered. 
 
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 E0673 (LT, RT) is segmental gradient pressure 
pneumatic appliance, half leg.  
We find that CPT code E0673 (LT, RT) is not supported in the medical record. Specifically, the enrollee used 
the equipment in the facility during and/or after surgery. Payment for this service would have been included 
under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the 
surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic appliances 
have not been met. Therefore, we decided that the Plan does not have to pay for the segmental pneumatic 
appliances (E0673) provided July 1, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 66984 provided on November 1, 2021. 
 
You asked the Plan to pay for procedure code 66984. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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 not provided enough evidence to support the denial of payment for 
procedure code 66984 based on Medicare criteria. Therefore, we decided that the Plan has to pay for procedure 
code 66984 provided on November 1, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you are 
appealing the denial of the Freestyle Libre 2 Sensor. The Plan denied your request. The Plan says you do not 
require insulin three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from May 10, 2022, to 
May 11, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you have provided medical records 
to support payment. The Plan denied your request. The Plan says these services are not payable as billed 
because you incorrectly billed as an outpatient hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare defines certain services as "inpatient-
only", which means that the services are not appropriate to be furnished in an hospital outpatient department. 
There is no payment under the Outpatient Prospective Payment System for services that Medicare designates to 
be inpatient-only services. 
 
In this case, one of the procedure codes that you billed (43775) is on the 2022 Medicare inpatient-only list. 
However, you billed these services as outpatient hospital services. Medicare does not permit payment of 
inpatient-only services on an outpatient hospital bill.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient hospital services provided from May 10, 2022, to May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support the 
medical necessity of these services. The Plan denied your request. The Plan says you billed with an incorrect 
place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223-57 billed for date of service September 21, 2022. 
 
You asked the Plan to pay for code 99223-57. You say that you billed this E/M service with a 57 modifier, so it 
should be separately paid. The Plan denied your request. The Plan says there is no separate payment for this 
code, and you did not bill it with an appropriate modifier to allow for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for an E/M service billed 
with 57 if it was provided on the day of, or the day before, a procedure with a 000- or 010-day global surgical 
period.  In this case, the surgical procedure performed (code 33316) is considered a minor surgery with a 000-
day global surgical period. However, you billed the E/M service in dispute with a 57 modifier, which is not 
permissible for services related to a minor surgery.  The 57 modifier only allows for separate payment of the 
E/M service if it is related to a major surgery.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99223-57 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 99223-57 billed for date of service September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office or other outpatient visit, 30-44 minutes 
(code 99203) provided on July 20, 2022. 
 
You asked the Plan to pay for the new patient office or other outpatient visit, 30-44 minutes. The Plan denied 
your request. The Plan says the members claims history shows that the member had an office visit (99212 25) 
on September 10, 2020, which was processed and paid by the Plan on behalf of the same non-participating 
provider on September 30, 2020, with check number 51330488. 
 
The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" means a patient who has 
not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) 
from the physician or physician group practice (same physician specialty) within the previous 3 years. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the new patient office or other outpatient visit, 30-44 minutes have not been met. Therefore, we 
decided that the Plan does not have to pay for a new patient office or other outpatient visit, 30-44 minutes  
(code 99203) provided on July 20, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a bone density scan (code 77080) provided on May 13, 2022. 
 
You asked the Plan to pay for the bone density scan. You say that the bone density scan was medically 
necessary. The Plan denied your request. The Plan says that this service does not meet the coverage 
requirements in the applicable Local Coverage Determination (LCD) or National Coverage Determination 
(NCD). Related services performed in connection with the denied procedure are also 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. Specifically, the Plan has not provided a Medicare rule to substantiate their 
denial. Therefore, we decided that the Plan has to pay for a bone density scan (code 77080) provided on  
May 13, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for a COVID-19 at-home test kit provided on August 15, 2022. 
 
You asked the Plan to reimburse you for the COVID-19 at-home test kit. You say that you were told this would 
be covered. The Plan denied your request. The Plan says that the member was not eligible at the time of 
service. 
 
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. Specifically, the Plan has not provided a Medicare rule or regulation to 
substantiate their denial. Therefore, we decided that the Plan has to reimburse you for a COVID-19 at-home 
test kit provided on August 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 23, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on August 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on June 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed.  
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 323. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided on June 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the knee (73721). 
 
You asked the Plan to pre-approve an MRI of the knee. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the knee. Our reviewer says 
that the services are medically necessary. Our physician reviewer found right knee was noted to be swollen on 
physical exam which is consistent with a joint effusion. The provider notes state the enrollee has had extensive 
physical therapy (PT) and conservative management without relief however, records of PT are not in the chart. 
The crepitus and joint effusion provide adequate indications for an MRI and the mentioned lacking of plain x-
rays would not be of consequence and the results would not negate the need for MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the knee have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the knee (73721).  
 
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.