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

 
We decided that the Plan does not have to pre-approve a PUREWICK TM external female urine collection 
device (K1006). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has skin break down that 
has not had time to heal and needs the device for the wounds to heal properly. The Plan denied your request. 
The Plan says the requested device is not a covered incontinence supply because they are disposable, non-
reusable hygiene items and fall outside the scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PUREWICK TM external 
female urine collection device (K1006).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric/detoxification treatment 
services provided from May 8, 2022, through May 12, 2022. 
 You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the inpatient services provided were not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
inpatient psychiatric/detoxification services provided were not medically necessary. Our physician reviewer 
found that the enrollee was admitted to the acute inpatient psychiatric/detoxification hospital with Alcohol 
Dependence and Opioid Dependence. Based upon the review of the records provided, it was not expected this 
enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, 
auditory or visual hallucinations, delusions, and was not showing any behavioral issues. It did not appear 
medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather 
than a lower level of care. The health plans denial for payment of the inpatient psychiatric services appears 
appropriate. This enrollee did not appear to require inpatient psychiatric care/detoxification treatment as he was 
not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was 
taking place. It did not appear that the services were reasonably expected to improve the enrollees condition or 
were for the purpose of a diagnosis. Based upon the review of the records provided, this enrollee does not meet 
criteria for coverage of the acute inpatient psychiatric care/detoxification treatment rendered.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric/detoxification treatment services provided from May 8, 2022, 
through May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye refraction (92015) provided on February 12, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that this eye refraction should be covered. The Plan 
denied your request. The Plan says that this service is not covered by Original Medicare and was performed 
with a medical eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine vision exam per year, including eye refraction for eyeglasses/contacts. 
The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward 
to the IRE information regarding its decision to deny coverage or payment. 
 
We looked at the file and the Plan's rules. The Plan argues that this service cannot be covered as it was 
provided with a medical eye exam; however, the Plans contract places no clear limitation on this service. An 
eye refraction is a routine eye exam, which is listed as covered under your supplemental benefit. In addition, 
the Plan has not provided a copy of the claim as it was originally submitted to the Plan for payment. Without 
this information, we cannot verify that the eye refraction at issue was provided for medical purposes. Based on 
this information, we decided that the Plan's rules for coverage of the eye refraction have been met. Therefore, 
we decided that the Plan has to pay for the eye refraction (92015) provided on February 12, 2021.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for the 
highest potential level of recovery. 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. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services twice per week for 4 
weeks to be provided out-of-network. 
You asked the Plan to pre-approve PT services. You say that you have been treating the enrollee since April 
2022. You say that the enrollee's only form of transportation is their daughter. You also say that interruption in 
care would negatively affect the enrollee's progress. The Plan denied your request. The Plan says there are in-
network providers available to provide the requested care. 
 
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. 
 
You are not a network provider with the Plan. The Plan has confirmed there are 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 physical 
therapy (PT) services twice per week for 4 weeks to be provided out-of-network.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on May 5, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service was rendered by an out-of-
network provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483) provided on May 18, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and was provided 
as ordered. The Plan denied your request. The Plan says with the information provided, it cannot be determined 
how the enrollee came to the servicing provider or whether the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules say that while a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent for the testing to be performed. Tests 
which are not ordered by the physician who is treating the enrollee are not reasonable and necessary. 
 
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 drug testing have been met. 
Specifically, the physician order provided includes a single page which does not include an itemized list of 
drugs or drug classes requested for testing. In addition, the physicians signature is illegible, and there is no 
clear documentation from this provider to show that they are currently treating the enrollee and have intention 
for this testing to be performed. Therefore, we decided that the Plan does not have to pay for drug testing 
services (G0483) provided on May 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine additional transportation trips. 
 
You asked the Plan to pre-approve routine additional transportation trips. You say that you require additional 
transportation for dialysis. The Plan denied your request. The Plan says that this request exceeds your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve routine additional transportation trips.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve four (4) home skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the request for care does not require the skills of a licensed 
nurse. 
 
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 home health services. Our reviewer 
says that four (4) home skilled nursing visits are medically reasonable and necessary. Clinical documentation 
shows that you have had recent acute on chronic heart failure decompensation with medication changes and 
would be expected to require assessment by a professional nurse to monitor blood pressure, heart rate, volume 
status and weight. Our physician reviewer found that your condition meets Medicare criteria for home health 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve four (4) home skilled nursing visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that the enrollee has multiple active comorbidities and would be expected 
to require close medical supervision on an inpatient basis during rehabilitation. Evaluating physical and 
occupational therapists recommend intense therapy. Thus, IRF criteria have been met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the documentation 
submitted does not provide sufficient supporting evidence of medical necessity.  
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 did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that this is a continuation of medication. The Plan 
denied your request. The Plan says Medicare part B coverage does not apply oral Methotrexate in this case 
because the enrollee is not being treated for cancer. The Plan also says that the Plan does not have a benefit that 
goes beyond the Medicare Part B benefit regarding self-administered medications. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methotrexate.  
 
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care visits provided on April 17, 2022 to 
April 18, 2022, by an OON provider. 
 
You asked the Plan to pay for subsequent hospital care visits. You say that you are appealing the date of service 
and submitted medical records for reconsideration.  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 subsequent hospital care visits provided on April 
17, 2022 to April 18, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
receiver (K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM receiver. You say that you are having issues with 
the other machine and not getting enough blood from your finger. The Plan denied your request. The Plan says 
you do not meet coverage criteria for the requested item. 
 
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 receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) receiver (K0554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 51785, 95861 and 95939 billed for date of 
service December 10, 2021. 
 
You asked the Plan to pay for procedure codes 51785, 95861 and 95939. You say that medical records are 
attached, and the claim should be reprocessed accordingly. The Plan denied your request. The Plan says 
procedure codes 51785, 95861 and 95939 are not supported by the medical records submitted. 
 
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 51785 is needle electromyography studies (EMG) of anal 
or urethral sphincter, any technique. The CPT Code Manual definition of code 95861 is needle 
electromyography; 2 extremities with or without related paraspinal areas. The CPT Code Manual definition of 
code 95939 is central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.  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 procedure codes 51785, 95861 and 95939. Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the procedure report does not include enough detail to confirm these procedures were performed. 
Therefore, procedure codes 51785, 95861 and 95939 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 51785, 95861 and 95939 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 51785, 95861 and 95939 billed for date of 
service December 10, 2021.