Persius/hicric huggingface dataset:
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 the services are necessary to ensure a safe return 
home for the enrollee. The Plan denied your request. The Plan says the enrollee could receive care in another 
setting. 
 
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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 31, 2022, to 
August 29, 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 claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that the admission date on the NOA must always match the 
From date.  
  
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the file 
shows that an invalid NOA with an admission date of May 7, 2021, and a "From" date of July 31, 2022, was 
submitted. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
July 31, 2022, to August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 provided on August 30, 2022. 
 
You asked the Plan to pay for procedure code 85060. 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 must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for procedure code 85060 provided on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor kit. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria are not met. 
 
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 treat with 
insulin three or more times per day or use an insulin pump. 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 pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment  includes placement (D6057), and abutment supported porcelain fused 
to metal crown (high noble metal) (D6059). 
 
You asked the Plan to pre-approve codes D6010, D6057, and D6059. You say that you need the implants 
because you don't have enough bone in the lower part. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment  includes 
placement (D6057), and abutment supported porcelain fused to metal crown (high noble metal) (D6059).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 3 continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM system. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the request does not meet criteria, does not meet the standard of 
care, and is therefore not medically necessary. 
 
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 3 CGM system have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre Kit 3 continuous glucose monitor (CGM) sensor.
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 you will be back in the hospital if you 
don't get the care you need. The Plan denied your request. The Plan says when you are ready to leave the 
hospital, you can safely receive this care in another setting, such as a skilled nursing facility, at home with 
home health services or in an outpatient setting if appropriate. 
 
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 you are presently receiving appropriate services in the acute care setting. Continued 
care in the short-term acute hospital is appropriate until you are stable to transfer to a lower level of care such 
as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns for tooth #19, 20, 21, 23, 
25, 26, 28, and 30 (D6058) and pontics for tooth #18, 22, 24, 27, 29, and 31 (D6245). 
 
You asked the Plan to pre-approve the crowns and pontics. You say that you disagree with the denial for the 
requested dental services. The Plan denied your request. The Plan says that the code submitted for restoring 
implants with retainer crowns is not correct. 
 
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. The Plan covers the crowns 
and pontics when the services are medically necessary and reasonable.  
 
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 crowns and pontics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the Plan was correct that the 
services were requested with an incorrect code and reviewed if the criteria for the correct code were covered. 
Connected abutments and pontics would constitute the final bridge restoration and the proper abutment code to use would be D6068. Pontics are only considered under the coverage where the rest of the prosthesis is a 
covered service. For a standard bridge the pontic code used would be appropriate and a covered service, 
however as the proper abutment codes for a fixed bridge supported by implant abutments were not utilized, the 
non-covered bridge abutment codes would disallow the requested pontic codes as well. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and pontics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve abutment supported crowns for tooth #19, 20, 21, 23, 25, 26, 28, and 30 (D6058) 
and pontics for tooth #18, 22, 24, 27, 29, and 31 (D6245).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 24, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that you would like the Plan to reconsider their 
denial of payment. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on November 02, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that these services were medically 
neccesary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on November 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that you are requesting a CGM 
and supplies. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a 
therapeutic CGM. 
 
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. Supporting medical records, were not submitted with this request. 
Without supporting medical records, you have not shown that coverage is appropriate at this time. Based on 
this information, we decided that there is insufficient information in the record to determine if Medicare rules 
for coverage of a therapeutic CGM and supplies have been met. medical records. Therefore, we decided that 
the Plan does not have to pre-approve a therapeutic CGM and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs a higher level of care. The Plan 
denied your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on September 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a computed tomography (CT) scan 
provided on August 13, 2021. 
 
You asked the Plan to reduce the coinsurance for a CT scan. You say that you have not been charged this 
amount for this service in the past. 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 20% 
coinsurance for Medicare-covered special imaging procedures, including CT scans.  
 
You have been asked to pay $695.01, which is 20% coinsurance of the allowed amount for a CT scan 
($3,475.06  allowed amount x 20% coinsurance = $695.01). This item/service falls within the outpatient 
diagnostic tests 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 reduce the coinsurance for a computed tomography 
(CT) scan provided on August 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 22, 2022. 
 
You asked the Plan to pay for ambulance services.. You say that the claim needs to be reconsidered for 
payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI. 
 
You asked the Plan to pre-approve SSBCI. You say that you have chronic conditions that will result in hospital 
stay at any given moment. The Plan denied your request. The Plan says there is no documentation that the 
member meets criteria. The Plan also says that multiple phone call attempts were made to the member and 
provider requesting medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we have confirmed that you do not have one of the eligible 
conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-
approve SSBCI.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 provided on November 9, 2022. 
 
You asked the Plan to pay for procedure code 85060. 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 must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for procedure code 85060 provided on November 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on September 21, 2022. 
 
You asked the Plan to pay for an ultrasound. You say that the claim needs to be reprocessed. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
   
The enrollee ended Medicare Hospice benefits on September 19, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an ultrasound 
provided on September 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood glucose monitor from an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
a home blood glucose monitor from an out-of-network (OON) provider.