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

 
We decided that the Plan does not have to pre-approve supplies for a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM supplies. You say that the requested supplies are a medical necessity 
for you. The Plan denied your request. The Plan says rules for coverage of CGMs and related supplies have not 
been 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve supplies 
for a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service June 28, 
2022. 
 
You asked the Plan to pay for procedure code 20936. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 20936 is considered bundled and 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 procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up battery. 
 
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 not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a back-up battery.
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 longer the enrollee stays in the hospital the less 
likely they will regain max. function. Enrollee needs constant chemotherapy and would do better at an acute 
rehab facility. The Plan denied your request. The Plan says the request is not medically necessary, the enrollee 
can safely receive the services they need in other settings, for example: 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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed on August 29, 2022. 
 
You asked the Plan to pay for code 99285. The Plan denied your request. The Plan says the billed code is 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function". 
 
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 code 99285. Our reviewer says that the use of code 99285 is not supported by the records provided. Our reviewer found that per CPT guidelines for emergency department 
services, 3 of 3 key components must be met or exceeded. In this case, history was complete; the exam was 
comprehensive, and medical decision making was minimal. The medical record does not support code 99285, 
as 3 of 3 key components were not met or exceeded. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed on August 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Orthovisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have osteoarthritis of the knee. The documentation does not support that you have tried and failed 
Euflexxa, Durolane, Supartz-FX, or Gelsyn-3. The documentation does not support that Euflexxa, Durolane, 
Supartz-FX, or Gelsyn-3 would likely be less effective and/or likely have adverse effects. Therefore, you do 
not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre reader device. 
 
You asked the Plan to pre-approve a Freestyle Libre reader device. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies have not been 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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre reader device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre reader device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 27, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service October 27, 
2021.  
You asked the Plan to pay for procedure code 99233. You say that the enrollee needed the services as they 
were unable to walk nor stand. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed. 
 
The Plan must follow Medicare rules. Review of claims history shows the exact same service (99233) was 
already billed for this enrollee and date of service by the same provider. You did not provide all the required 
evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 99233 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99233 billed 
for date of service October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visual field examination (92083), gonioscopy (92020), 
and outpatient office visit (99213) provided on June 24, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the visual field examination, gonioscopy, and outpatient office visit. You say that 
you were not aware that the enrollee should have had prior approval for these services because the provider is 
not in-network. The Plan denied your request. The Plan says prior authorization was required but 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 requested 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 visual field examination (92083), gonioscopy 
(92020), and outpatient office visit (99213) provided on June 24, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor (K0554) 
 
You asked the Plan to provide the continuous glucose monitor. You say that the services should be covered as 
you disagree with the denial and the monitor is medically necessary. The Plan denied your request. The Plan 
says the services denied correctly as the record indicates that you inject insulin twice per day, therefore do not 
meet the clinical requirements to be approved. 
 
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 you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. 
Therefore, we decided that the Plan does not have to provide a continuous glucose monitor (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on May 4, 2022. 
 
You asked the Plan to pay for the prophylaxis. You say that you did not pay for this service because the 
provider needed to submit the claim for payment. The Plan denied your request. The Plan says you are not 
eligible for benefits. 
 
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 contract clearly states that requests 
for reimbursement must include itemized receipts. The documentation provided does not include an itemized 
receipt, and you also state in your appeal that you did not pay for this service. To have been eligible for 
payment for this service, you would have needed to pay out-of-pocket for it initially, and then send an itemized 
receipt with your request for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) provided on May 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the home health services. You say that the enrollee is blind and unable to 
self-administer medications. You also say that the enrollee continues to need skilled nursing services, home 
health aide, and physical therapy for assistance and gait training/strength. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 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 the home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs or skilled therapy needs. The enrollee is bedfast and dependent 
for activities of daily living. Our reviewer found that daily skilled services are not required to assist in the 
treatment of an acute illness or injury. Our physician reviewer also found that the enrollees care needs are 
custodial and long-term. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure of the left lower leg. 
 
You asked the Plan to pre-approve a revascularization procedure of the left lower leg. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a revascularization procedure of the left 
lower leg. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support the medical necessity 
of the treatments in question. There is documentation that the enrollee denies claudication and has palpable 
posterior tibial pulses bilaterally. His chief complaint was that he had some discomfort and wanted his 
circulation checked. There is no evidence that the enrollee has limb threatening ischemia. The enrollee had no 
difficulty completing the exercise ankle brachial index (ABIs) which demonstrated no change post exercise. 
The noninvasive studies did not demonstrate disease above the popliteal arteries bilaterally. Treatment of 
infrapopliteal disease in the absence of limb threat is likely to cause more harm than good. 
 
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 revascularization procedure of the left lower leg have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a revascularization procedure of the left lower leg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system. 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the member does not use insulin with at least three daily injections. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) (e.g., 5-
fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (e.g., *2A, *4, *5, *6) 
(81232) provided January 6, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this letter documents the medical necessity of 
the test requested for the enrollee to inform treatment selection for their cancer. The Plan denied your request. 
The Plan says Genetic testing procedures submitted under CPT code 81232 are non-covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. 81232 is listed under Tier 1 noncovered codes. This testing is 
unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
DPYD (dihydropyrimidine dehydrogenase) (e.g., 5-fluorouracil/5-FU and capecitabine drug metabolism), gene 
analysis, common variant(s) (e.g., *2A, *4, *5, *6) (81232) provided January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of a venous access port and ultrasound at 
California Hospital Medical Center. 
 
You asked the Plan to pre-approve removal of a venous access port and ultrasound at California Hospital 
Medical Center. You say that the services are necessary. The Plan denied your request. The Plan says medical 
necessity has not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve removal of a venous access port and 
ultrasound at California Hospital Medical Center. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the procedure was 
approved but the hospital admission was not approved. However, the provided documentation did not suggest 
the enrollee required inpatient services as there was no evidence of instability. A lower level of care 
(observation, outpatient) is recommended to perform the venous port removal. Therefore, this request will be 
considered not medically necessary as requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of removal of a venous access port and ultrasound at California Hospital Medical 
Center have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of a 
venous access port and ultrasound at California Hospital Medical Center.