Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a freestyle libre 3 sensor. 
 
You asked the Plan to pay for the freestyle libre 3 sensors. You say that the item should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the item denied correctly as it is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the freestyle libre 3 sensor have not been met. Specifically, the requested CGM device does not 
meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. 
Therefore, we decided that the Plan does not have to pay for a freestyle libre 3 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) provided to the 
enrollee on May 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223-AI (1 unit) remains not supported. 
 
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 [Enter billing code at issue (e.g. 43856, K0002, etc.)] is 
"Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which 
requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT 99223 was used; however, it 
was not sufficiently supported in the provided documentation. The documentation included a basic history and exam but does not meet definition of comprehensive (at least 3 chronic conditions updated in depth, more in 
depth examination). Also, the records do not support medical decision making of high complexity as the patient 
had stable vitals and required only a focused treatment for her epistaxis. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) provided to the enrollee on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary for your 
medical condition. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray provided on October 21, 
2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you were told you would not have any 
cost share amount for this service. 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 $100 
copayment for x-rays performed in an outpatient hospital facility.  
 
You have been asked to pay $76.40, which is less than the standard $100 copayment for the x-ray. This 
item/service falls within the outpatient diagnostic testing and therapeutic services 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 the chest x-ray provided on October 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic physical therapy. 
 
You asked the Plan to pre-approve aquatic physical therapy. You say that you feel aquatic therapy would 
benefit your current medical condition. The Plan denied your request. The Plan says member has been able to 
tolerate land-based therapy and can be evaluated in PT. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 aquatic physical therapy. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found review of literature found little support for aquatic therapy 
over land therapy to address arthritis. The request is not medically necessary as there is no long-term benefit of 
aquatic therapy over land therapy. You are able to do land therapy. The requested therapy is not reasonable for 
your condition and not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic physical therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aquatic physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on October 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that you have tried to obtain 
authorization for the service billed. You also say that the services were performed before the authorization was 
obtained due to their condition. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 in this case is not a network provider with the Plan. 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 office visit (99214) provided on October 19, 2022, by an out-
of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is at risk of falling. The Plan denied 
your request. The Plan says the Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. 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 not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader and sensor kits. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day reader and sensor kits. You say that the enrollee 
has a history of diabetes and hypoglycemic episodes. The Plan denied your request. The Plan says the enrollee 
does 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 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 a 
Freestyle Libre 14 day reader and sensor kits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 14 day reader and sensor kits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 CGM. You say that the enrollee has a history of high 
A1C levels. Despite his efforts to manage his diabetes with regular blood glucose testing, he continues to 
struggle with keeping his levels under control. Furthermore, he has a needle phobia that makes it difficult him 
to comply with regular fingerstick testing. The Plan denied your request. The Plan says a continuous glucose 
monitor is covered under Medicare only if an enrollee with diabetes is on insulin several times a 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 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 Kit 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre Kit 2 continuous glucose monitor (CGM) sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power wheelchair (K0815). 
 
You asked the Plan to pre-approve a group 1 standard power wheelchair. You say that the enrollee has 
difficulty walking. The Plan denied your request. The Plan says there is no documentation for medical 
necessity need for a Group 1 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 a group 1 standard power wheelchair. 
Our reviewer says that this is not medically necessary. Our physician reviewer found the records in this case do 
not clarify that the enrollee's mobility deficit cannot be helped using a manual wheelchair. A face-to-face 
examination note of February 17, 2023, reports that the enrollee's mobility deficit could be managed using a 
manual wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 1 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 1 standard power wheelchair (K0815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee failed to improve despite the 
use of continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) while 
hospitalized. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  The enrollee has a diagnosis of COPD.  The enrollee was recently hospitalized, and an 
arterial blood gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure.  The 
circumstances of the hospitalization are not provided.  There are no pulmonary function tests to confirm the diagnosis of COPD and assess severity.  There is no arterial blood gas done while stable to confirm chronic 
carbon dioxide (CO2) retention.  If this enrollee does have severe COPD and chronic CO2 retention, they may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep.  There is no 
documentation that this has been tried and shown to fail as an outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a 
lumbar laminectomy and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the enrollee is approved for a lumbar laminectomy. The record does not document 
that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total hip arthroplasty (27130) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the total hip arthroplasty. You say that the service should be covered. The 
Plan denied your request. The Plan says there are in-network providers that can perform this service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the total 
hip arthroplasty (27130) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for psychotherapy services provided on 
September 15, 2022. 
 
You asked the Plan to reduce the copayment for psychotherapy services. You say that you think that the cost 
sharing should be lower. 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 $65 
copayment for out-of-network mental health services provided at a specialists office. 
 
You have been asked to pay a $65 copayment for psychotherapy services. This item/service falls within the 
out-of-network mental health services provided at a specialists office 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 copayment for psychotherapy services provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941), hot or cold 
packs therapy (97010), and electric stimulation therapy (97014) to be rendered by the out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the services are available with in-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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic manipulative treatment (98941), hot or cold packs therapy (97010), and electric stimulation 
therapy (97014) to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power mobility device to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve power mobility device. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says as a member of the plan, the enrollee must use network providers. 
If the enrollee receives unauthorized care from an out-of-network provider, the plan may deny coverage and the 
enrollee will be responsible for the entire cost. 
 
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 
power mobility device to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on March 28, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
March 28, 2022.