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

We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided from July 23, 2020, 
through July 31, 2020, billed with code FAPF1. 
 
You asked the Plan to pay for the SNF services as billed. You say that the Section GG clarification documents 
the overall picture of the enrollee's first three days of the SNF stay. Although the dates are not explicitly stated, 
it is understood that an admission evaluation would refer to these dates. The Plan denied your request. The Plan 
says that the documentation is not sufficient to support the usual functional ability coding for Section GG 
meaning that the billed HIPPS code is not supported. 
 
The Plan must follow Medicare rules. The rules 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan's denial rationale is not sufficiently specific to justify 
adjustment of the billed HIPPS code. It is noted that the Section GG Clarification cannot be used to justify the 
coding on the Minimum Data Set (MDS) assessment simply because it does not specify the three-day period it 
is referencing. However, as argued by the provider, the three-day lookback period for the reporting of usual 
functional abilities on admission is always the first three days of the admission. Since this document is 
identified as being done as an admission evaluation and reports for the three-day lookback period, it is known 
that this refers to the first three days of the admission. In addition, the Plan has failed to identify any specific 
discrepancy between what is reported on the MDS form and what is documented in the rest of the record. We 
find that adjustment of the physical/occupational therapy and nursing case-mix groups is not supported based 
on the evidence provided. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) 
care provided from July 23, 2020, through July 31, 2020, billed with code FAPF1.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
system and standard supply allowance. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM system and standard supply allowance. You say that 
the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has 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 CGM system and standard supply allowance have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) system and standard 
supply allowance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) wheelchair 
accessories, 20" active reach seating system (K0108) and ability drive joystick (K0108) and ram x-grip phone 
holder (K0108). 

You asked the Plan to pre-approve the power electronics and power seat elevation system. You say that you are 
appealing the denial of the power electronics. The Plan denied your request. The Plan says the records do not 
show that these items are used to serve a medical purpose, these features are not primarily medical in nature 
and the wheelchair will be equipped with a 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the power electronics and power seat elevation system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the power seat elevation system (E2300) wheelchair accessories, 20" 
active reach seating system (K0108) and ability drive joystick (K0108) and ram x-grip phone holder (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system and electronic 
connection. 
 
You asked the Plan to pre-approve the power seat elevation system and electronic connection. You say that you 
would like reconsideration because the requested accessory is medically necessary. The Plan denied your 
request. The Plan says services that are not medically necessary are not covered under the health plan benefit.  
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature. 
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The requested 
accessory is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-
approve the power seat elevation system and electronic connection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulmonology services to be provided by an out-of-
network (OON) provider.  
You asked the Plan to pre-approve OON services. You say that the enrollee needs additional visits for future 
treatment. The Plan denied your request. The Plan says the enrollee does not require a third opinion by an out-
of-network provider.  
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
pulmonology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and routine electrocardiogram 
(93000) provided on April 6, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and routine electrocardiogram. You say that these services were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services rendered by an OON provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99214) and routine 
electrocardiogram (93000) provided on April 6, 2021 by an out-of-network (OON) provider.
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 IRF care is medically necessary and supported by the 
records provided. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for gangrene and peripheral vascular disease and had a below the knee amputation. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that this 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission from November 4, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric admission from November 4, 2021, forward. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services are 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 pre-approve inpatient psychiatric admission from 
November 4, 2021, forward. Our reviewer says that the documentation does not support that the requested Our 
physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on 
October 15, 2021, with Bipolar Disorder, Severe, Current Episode Manic without Psychotic Features. Based 
upon review the records provided, the enrollee does not meet the criteria for continued acute inpatient mental 
health treatment for the dates in question of November 4, 2021, forward as the enrollee was not shown to be a 
danger to herself or others. The enrollee was not showing any auditory or visual hallucinations and was 
cooperative/compliant with treatment. The enrollee was not showing any aggressive behaviors, or any signs of 
acute threats of safety. Therefore, the enrollee does not meet criteria for the requested continued 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 inpatient psychiatric admission from November 4, 2021, forward have not been 
met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission from 
November 4, 2021, forward.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need this before returning home. The Plan 
denied your request. The Plan says that you can be treated at a lower level of care. 
 
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 medically necessary. Our physician reviewer found the records show that you currently 
require daily wound care. Daily skilled services are required to establish a maintenance program or to prevent 
deterioration of your condition. It has not been shown that your wound can be managed by a lower 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) for teeth # 22 and 27 provided on 
July 7, 2021. 
 
You asked the Plan to pay for the core build up. You say that the core build up was medically necessary. The 
Plan denied your request. The Plan says the core build up are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950) for teeth # 22 and 27 provided on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on 
March 5, 2021. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (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 Healthcare Common Procedure Coding System (HCPCS) code 
G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 
 
We find that HCPCS code G0483 is not supported in the medical record. Specifically, Specifically, the place of 
service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The 
claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of 
a doctor's office (POS 11). 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 drug testing services 
(G0483) provided to the enrollee on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub or bathtub conversion. 
 
You asked the Plan to pre-approve tub or shower equipment of any kind. You say that a walk-in tub is 
necessary for safety. The Plan denied your request. The Plan says this type of equipment is not covered by the 
Plan or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower and bath equipment is not covered 
because it is not primarily medical in nature. While a walk-in tub or shower may be appropriate in this case, 
neither the Plan nor Medicare offers coverage for this type of equipment or conversion. Therefore, we decided 
that the Plan does not have to pre-approve a walk-in tub or bathtub conversion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee needs the 
reduced pressure and gentle treatment application only afforded by the prescribed E0652. The Plan denied your 
request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there 
is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve office visits to be rendered by the 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 there are in-network providers available to render 
the requested services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 twelve 
office visits to be rendered by the OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare 
due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research needed to show safety and efficacy. Our physician reviewer found that your 
condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve waterjet ablation procedure of the prostate (0421T). 
 
You asked the Plan to pre-approve waterjet ablation procedure. You say that you understand that the procedure 
is being denied because of your age, but that is one of the reasons you believe the procedure would benefit you 
and your overall health. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for coverage. 
 
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. The Medicare criteria for waterjet ablation of the prostate is to be 80 
years of age or less. The enrollee is 85 years old which is outside of the Medicare criteria. Based on this 
information, we decided that Medicare rules for coverage of waterjet ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve waterjet ablation procedure of the prostate 
(0421T).