Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 
14, 2021. 
 
You asked the Plan to pay for the dental service. You say that you could not have anticipated this denial of 
payment. You also say that you had no control over how the claim was coded. The Plan denied your request. 
The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has 
been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on September 15, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 5, 2021. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2021. 
 
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 not billed correctly. 
 The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on January 24, 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 the services are 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 CPT code. In this case, we have confirmed that code 71045 is a column II code to column I code 36556. 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 the chest x-ray 
rendered on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 1, 2020. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI. 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on December 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
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 Restasis for the enrollee.  
 
 
 Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an opioid treatment program provided on June 1, 2021. 
 
You asked the Plan to pay for an opioid treatment program. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 opioid treatment program provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 the laboratory services provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the FreeStyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pay for the FreeStyle Libre 2 CGM. You say that you would like reconsideration 
because the requested CGM is medically necessary. The Plan denied your request. The Plan says that the 
records do not show that the enrollee frequently adjusts their insulin treatment. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the FreeStyle Libre 2 CGM. Our reviewer 
says that the enrollee meets Medicare criteria for coverage of the requested CGM. Our physician reviewer 
found the record show that the enrollee was to titrate the doses of their insulin to their blood glucose level. This 
suggests that they adjust their insulin treatment regimen each day/meal. The record also shows that the enrollee 
is insulin treated 4 times per day. 
 
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 FreeStyle Libre 2 CGM have been met. Therefore, we decided that the Plan 
has to pay for the FreeStyle Libre 2 continuous glucose monitor (CGM).  
 
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 pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would be a fall risk without a transfer to SNF 
care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF services do 
not meet the requirements for approval. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the enrollee is not a functional 
ambulatory and has had multiple falls due to mobility deficits. The Plan denied your request. The Plan says the 
records do not support that the enrollee meets the Medicare criteria for the requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation is not consistent that the enrollee has a mobility deficit that 
interfered with MRADLs in the home.  An 11/17/21 physician note indicates normal gait. A 3/8/22 physician 
note indicates trouble with walking "long distances" and "short of breath after walking 30 yards" however the 
enrollee had a COPD exacerbation at this time and was treated with medications. The physician documentation 
does not reveal a detailed neuromuscular and musculoskeletal exam indicating why an appropriately fitted 
walker or manual wheelchair would not work. The physician documentation does not reveal specific limitations 
in MRADLs. The physical therapy note states that OA limits hand grip strength but the physician exam notes 
no focal neuro deficit. The 3/8/22 document by the physician review of systems indicates no joint swelling, 
arthralgia, joint swelling or evidence of arthritic deformities that would limit hand use. The documentation is 
not clear that the requested Group 2 wheelchair will significantly improve MRADL participation in the home. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the group 2 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 28, 2021, to May 
2, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not supported as the diagnosis of severe sepsis with septic shock (R65.21) is not supported in the medical record. 
The Plan argues that the diagnosis of severe sepsis without septic shock (R65.20) is supported, and therefore 
DRG 872 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of severe sepsis with septic shock (R65.21) is not supported in the record for 
this inpatient admission. Our physician reviewer found that the enrollee had a history of depression, 
hypertension, diabetes mellitus, gastroesophageal reflux disease, pancreatitis and arthritis, and presented for 
evaluation on April 28, 2021, with reported syncope, urinary retention, hyperglycemia and flank pain. The 
Emergency Department physician described the enrollee as having been alert and oriented to person, place and 
time; in no acute distress; with warm skin. The enrollee was admitted for further evaluation and management of 
suspected right-sided colitis with sepsis, receiving intravenous fluids and antibiotics. The enrollees blood 
pressure was generally in the mildly hypertensive range. Otherwise, blood pressure readings were mildly 
elevated to normal range. There was no clinical or laboratory evidence of sepsis. The review has determined 
that the medical records did not support the billing of severe sepsis with septic shock (R65.21). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from April 28, 2021, to May 2, 2021, as 
billed with Diagnosis Related Group (DRG) 871.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on August 23, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vacuum drainage collection unit and tubing kit, including 
all supplies needed for collection unit change (A7048) provided December 18, 2019 to December 25, 2019. You asked the Plan to pay for Vacuum drainage collection unit and tubing kit. You say that please review the 
claims as they were not processed correctly per Medicare. The Plan denied your request. The Plan says exceeds 
the contracted maximum number of hours/days/units by this provider for this period. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code A7048 is 2. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of Vacuum 
drainage collection unit and tubing kit have not been met. Therefore, we decided that the Plan does not have to 
pay for the vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit 
change (A7048) provided December 18, 2019 to December 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit steroid injection and x-rays of knee to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient services. You say that you have previously performed a knee 
replacement surgery for the enrollee. You also say that to your knowledge, there are no in network orthopaedic 
physicians in the enrollee's area. The Plan denied your request. The Plan says the requested services can be 
provided in network. 
 
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 
an office visit steroid injection and x-rays of knee to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Wearable, automatic, external defibrillators with integrated 
electrocardiogram analysis (K606) provided on July 18, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Zoll Life vest. You say that because the Plan has instituted an opaque 
process, it is often unclear to you whether a prior authorization request is required, is pending or has been 
issued. 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 Wearable, automatic, external defibrillators with 
integrated electrocardiogram analysis (K606) provided on July 18, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you had an unfair and inaccurate assessment for the 
rehabilitation. You say you need aggressive therapy in order to regain your independence. The Plan denied 
your request. The Plan says authorization denied because IRF is not medically necessary, and your needs can 
be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 you are medically stable and do not need close physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical 
conditions. You have no rehabilitation nursing needs identified or documented in the record. At the current 
level of function, you do not need 3 hours a day five days a week of IRF therapies with interdisciplinary 
management and your rehabilitation needs can be met in an alternate and lower setting such as in an SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair component or accessory, transit option (CPT 
code K0108). 
 
You asked the Plan to pre-approve the transit kit. You say that the transit kit, air tires and insert are needed for 
transporting to regular medical appointments. The Plan denied your request. The Plan says the transit kit is not 
covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although 
this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, 
we decided that the Plan does not have to pre-approve wheelchair component or accessory, transit option (CPT 
code K0108).