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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 continued SNF care have been met. No 
medical records have been submitted in support of the appeal. The Plan indicates that the facility at issue has 
not responded to requests for medical documentation. Therefore, we decided that the Plan does not have to pre-
approve continued SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 29, 
2022, to July 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are requesting 
reconsideration stating the hospital stay was the same issues as the hospital stay on June 11, 2022. 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 $345 
copayment for days 1 to 5. This inpatient hospital stay lasted 12 days, resulting in a copayment amount of 
$1,725 ($345 per day for 5 days = $1,725). 
 
You have been asked to pay $345 copayment for inpatient hospital care. This item/service falls within the days 
1 to 5 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 inpatient hospital care provided 
on June 29, 2022, to July 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96116 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 96116. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 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 96116 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 96116 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 96116 billed for date of service June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly exceeds the 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are 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. Our reviewer 
also found that 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that Avastin is not approved for his condition. The Plan 
denied your request. The Plan says step therapy requirements have not been met. 
 
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 Vabysmo. Our reviewer says that the 
requirements for coverage of Vabysmo have not been met. Our physician reviewer found the Plan requires a 
trial of Avastin before they will approve the requested drug. The record does not show that you have tried and 
failed the required drug. There is no documentation provided indicating that the required drug would likely be 
less effective or have adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve an inpatient admission. You say that you need to be admitted as an inpatient 
because your heart rate was too high after surgery. The Plan denied your request. The Plan says the inpatient 
admission is not medically needed because the criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an inpatient admission. Our reviewer 
says that the documentation does not support that the criteria for an inpatient admission are met in this case. 
Our physician reviewer found you presented to the hospital following cardioversion for atrial flutter, which was 
unsuccessful. Amiodarone drip was planned to help convert you to normal sinus rhythm. Our reviewer found 
that this is a request for inpatient services related to this medication administration. At the time of admission, 
you were otherwise stable and were already on Eliquis. Our physician reviewer also found that there is no 
indication from the provided documentation that you would require hospital services that would likely cross 2 
midnights. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an inpatient admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
June 30, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you are requesting 
reconsideration because you received the same services in December of 2021 and had no cost share. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for outpatient surgery. 
 
You have been asked to pay a $295 copayment for outpatient surgery services. This item/service falls within 
the outpatient surgery 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 outpatient 
surgery services provided on June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient rehabilitation stay from 
September 24, 2021, to October 1, 2021. 
 
You asked the Plan to waive the coinsurance for an inpatient rehabilitation stay. You say that you should not 
have to pay this coinsurance since you were not advised the provider was out-of-network. 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 40% 
coinsurance for out-of-network inpatient hospital care.  
 
 
  You have been asked to pay a coinsurance of $6,428.86, which is 40 % of the allowed amount for an inpatient 
rehabilitation stay ($16,072.16 allowed amount x 40% = $6,428.86). This item/service falls within the Inpatient 
Hospital Care 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 coinsurance for an inpatient rehabilitation 
stay from September 24, 2021, to October 1, 2021.  
 
Your complaint about not being informed the provider was out-of-network is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
reader. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM reader. You say that you disagree with the denial 
and are requesting reconsideration for the CGM reader due to type 2 diabetes mellitus without complications. 
The Plan denied your request. The Plan says you do not meet coverage criteria for approval of the CGM reader. 
 
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 a Freestyle 
Libre CGM reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and testing services provided on July 17, 2020 
and September 17, 2021, by an OON provider. 
 
You asked the Plan to pay for an office visit and testing services. You say that the office was unaware that this 
patient had this Plan at the time of service. You say that due to this no referral or authorization was obtained. 
The Plan denied your request. The Plan says the out-of-network 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 an office visit and testing services provided on 
July 17, 2020 and September 17, 2021, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300). 
 
You asked the Plan to pre-approve direct skilled nursing services of an RN and LPN. The Plan denied your 
request. The Plan says you do not meet the criteria for coverage for skilled nursing care. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 direct skilled nursing services of an RN 
and LPN. Our reviewer says that the requested services are not medically necessary, reasonable or coverable. 
Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer also found that 
twice daily nursing visits are not intermittent. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct skilled nursing services of an RN and LPN have not been met. Therefore, 
we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and direct skilled nursing services of a licensed practical nurse (LPN) (G0300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and two leg 
appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and two leg appliances. You say that you 
strongly disagree with this decision. The Plan denied your request. The Plan says medical criteria have not been 
met for the calibrated pneumatic compression device. The enrollee does not have lymphedema extending into 
the chest, trunk, or abdomen and no record of trial measurements was included. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and two leg appliances (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily physician 
rounding, and these services are medically necessary. The Plan denied your request. The Plan says a LTACH is 
not medically necessary because the enrollee's needs are being met at the current level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee 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. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided on February 17, 2022. 
 
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show the 
presence of a trained observer. Based on this information, we decided that Medicare rules for coverage of the 
sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation 
services (99152) provided on February 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37184, 37185, and 76937 billed for date of 
service February 7, 2022. 
 
You asked the Plan to pay for procedure codes 37184, 37185, and 76937. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
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 3.  
 
In this case, the MUE's for CPT codes 37184, 37185, and 76937 are 1, 2, & 2. The MAI value for this code is 
3. You billed 2, 5, & 3 units of these codes, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37184, 37185, and 76937 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 37184, 37185, and 76937 billed for date of 
service February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denied services with 
medical records. The Plan denied your request. The Plan says the rendering and referring providers are both 
OON providers and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 
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 May 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug delivery system provided on June 28, 2021 
to July 4, 2021, by an OON provider. 
 
You asked the Plan to pay for a disposable drug delivery system. You say that you are asking for this claim to 
be reviewed, reprocessed and paid. The Plan denied your request. The Plan says the out-of-network 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 a disposable drug delivery system provided on 
June 28, 2021 to July 4, 2021, by an OON provider.