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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you have been doing finger-stick testing and 
your current device has been broken for over a month. The Plan denied your request. The Plan says the criteria 
for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day or use an insulin pump. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heavy duty, extra wide hospital bed and foam rubber 
mattress (E0272). 
 
You asked the Plan to pre-approve the hospital bed and mattress. You say that you understand you do not meet 
the weight requirements of a larger bed, but you need to be able to turn over in bed to prevent pressure sores. 
You are paraplegic and is requesting an exception to the weight rule. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for the requested hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met:  
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
We looked at the file and Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is 
covered for a person who weighs more than 300 pounds and less than 600 pounds. The records show that you 
weigh 154 pounds. Based on this information, we decided that Medicare rules for coverage of the hospital bed 
and mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve the heavy 
duty, extra wide hospital bed and foam rubber mattress (E0272).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AccuChek BG test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred providers. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. 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 AccuChek BG test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 10, 2020, to November 23, 2020. 
 
You asked the Plan to pay for the services. You say that you do not agree with changing the DRG from 871 to 
180. The Plan denied your request. The Plan says the DRG was adjusted in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found there was no clinical or laboratory evidence of sepsis. DRG 180: 
RESPIRATORY NEOPLASMS WITH MCC is the more appropriate DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from November 10, 2020, to November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pay for Freestyle Libre continuous glucose monitor. You say that you cannot use finger 
sticks due to neuropathy and carpal tunnel. You have been paying for OneTouch Libre and it is too expensive 
to keep paying. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 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 their 
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 Freestyle Libre continuous glucose monitor have 
not been met. Therefore, we decided that the Plan does not have to pay for Freestyle Libre continuous glucose 
monitor.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF services provided from November 
9, 2021, through January 3, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you cannot pay this bill. The Plan 
denied your request. The Plan says the claims processed 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 $0 
copayment per day, for days 1-20 and a $150 copayment per day, for days 21-100 at a skilled nursing facility.  
 
You have been asked to pay a total of $1,850 for SNF services.  
 
Date of Service SNF Days Standard Copayment Member Liability 
November 9, 2021-
November 28, 2021 
1-20 $0/day $0 
November 29, 2021-
December 31, 2021 
 
21-53 $150/day $1,550-Less than 
standard because you 
met your Max OOP 
January 1, 2022- 
January 3, 2022 
54-55 $150/day $300 
TOTAL:   $1,850 
 
The SNF services falls within the "Skilled nursing facility (SNF) care" 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 SNF services provided from November 9, 2021, through January 
3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for hernia repairs (00750) provided on September 27, 2021. 
 
You asked the Plan to pay for the anesthesia for hernia repairs (00750). You say that the charges are separately 
payable and are not bundled with any other service. You say that anesthesia charges are reimbursed separately 
and payment should be processed. The Plan denied your request. The Plan says that the medical records do not 
support that a second anesthesia occurred on this date. 
 
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. The Plan says two anesthesia claims were billed on this date of service. The Plan 
did not submit documentation supporting another anesthesia claim was billed or already paid. It is the burden 
of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated 
so we must find in your favor. Therefore, we decided that the Plan has to pay for anesthesia for hernia repairs 
(00750) provided on September 27, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor 
(CGM). 
 
You asked the Plan to pre-approve the FreeStyle Libre CGM. You say that you would like reconsideration 
because the requested CGM is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare criteria for coverage. 
 
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 and 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 the FreeStyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle 
Libre Continuous Glucose Monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your record does not show that you require daily skilled nursing or 
skilled therapy in a SNF setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81210, 81235, 81275, 
81276, 81295, 81298, 81301, 81317, 81401, 81194, 81309, 81206, and 81292) provided on July 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Furthermore, for the 
procedure codes 81206 and 81292: The Plan states outreach to the ordering provider listed on the claim and 
medical records was made and the provider advised that they did not order the test. The denied services are not 
a covered benefit as there is no evidence to support the ordering provider is treating the enrollee. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81210, 81235, 81275, 
81276, 81295, 81298, 81301, 81317, 81401, 81194, 81309, 81206, and 81292) provided on July 17, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the eyeglass lens bases. We decided that the Plan does not have to pay 
for the lens upgrades.  
 
You asked the Plan to pay for eyeglass lenses with upgrades. You say that these services are necessary, and you 
need these upgrades because you are starting to develop cataracts. The Plan says that you have exceeded the 
frequency limitations of your benefit. 
 
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. 
 
We decided that the Plan has to pay for the eyeglass lens bases.  
 
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. Specifically, the Plan says that you have exhausted the frequency limitations of 
your benefit but did not provide any previous paid claim information or other documentation to show that you 
have used this benefit within the last two years. Standard single vision lenses are covered by this benefit. 
Therefore, we decided that the Plan has to pay for the base eyeglass lenses (V2103) provided on November 16, 
2021.  
 
We also decided that the Plan does not have to pay for the lens upgrades. 
 
You contract with the Plan states that additional lens options including, but not limited to, deluxe, premium or 
platinum progressive lenses, blended bifocal, hi-index, tinting, scratch coating, ultraviolet or anti-reflective 
coating, and polycarbonate are not covered. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested lens options or 
upgrades are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the polarization (V2762) and polycarbonate coating (V2784) provided on November 16, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the magnetic resonance angiography (MRA) of the chest (71555). 
 
You asked the Plan to pre-approve the MRA of the chest. You say that the service is medically necessary. The 
Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRA of the chest. Our reviewer 
says that the service is medically necessary. Our physician reviewer found a prior imaging study (CTA) 
demonstrated a dilated aortic root at 4.6 cm. The clinical documentation clearly states that the MRA was 
ordered for evaluation of a known thoracic aneurysm and regular imaging is recommended for surveillance of a 
thoracic aortic aneurysm. 
 
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 MRA of the chest have been met. Therefore, we decided that the Plan has to 
pre-approve the magnetic resonance angiography (MRA) of the chest (71555).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular services provided on July 15, 2021, billed with 
codes 37237, 36245, and 99152. 
 
You asked the Plan to pay for the vascular services. You say that the patient had multiple exams on this date. 
The Plan denied your request. The Plan says payment was already made for the services at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims must be denied but can be 
appealed.  
 
We looked at the file and Medicare rules. The file shows that payment was made for these services on a 
previous claim. There is no evidence that the second submitted claim is for separate services. Based on this 
information, we decided that Medicare rules for coverage of the vascular services have not been met. 
Therefore, we decided that the Plan does not have to pay for the vascular services provided on July 15, 2021, 
billed with codes 37237, 36245, and 99152.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36247) and aortography 
(75625) provided on November 30, 2021. 
 
You asked the Plan to pay for the selective catheter placement (36247) and aortography (75625). You say that 
the procedures were performed as prescribed in the report. You say that the documentation should be reviewed 
and payment for CPT codes 36247 and 75625 allowed. The Plan denied your request. The Plan says procedure 
codes 36247 and 75625 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 36247 is selective catheter placement, arterial system; 
initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular 
family. The CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
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 selective catheter placement (36247) and aortography 
(75625). 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 documentation of selective catheter 
placement or abdominal aortography. Therefore, these procedures 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 the selective catheter placement (36247) and aortography (75625) have not been 
met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36247) and 
aortography (75625) provided on November 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on November 18, 
2021, billed with codes 27130-AS-LT and 27299-AS-59-LT. 
 
You asked the Plan to pay for the surgical assistant services. You say that this was medically necessary 
treatment for which payment should be made. The Plan denied your request. The Plan says the provider at issue 
is not eligible to be reimbursed for surgical assistant services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on November 18, 2021, billed with codes 27130-AS-LT and 27299-AS-59-LT.