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

 
We decided that the Plan does not have to pre-approve a Purewick catheter system. 
 
You asked the Plan to pre-approve a Purewick catheter system. You say that you have limited mobility and 
cannot walk without assistance and has had frequent falls. You also have urinary frequency and get up often at 
night resulting in lack of sleep. You were hospitalized in late June 2022, and while hospitalized, a Purewick 
system was utilized to help manage your urinary drainage. You are now requesting a system at home due to 
medical necessity. The Plan denied your request. The Plan says in the PureWick urine collection system, the 
wands, tubing and canisters are all disposable. The suction pump is not disposable, but it is designed for use 
with the PureWick system only, not for other medical purposes. The requested system and its accessories are 
not currently eligible for Medicare reimbursement. 
 
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. Medicare rules show that while a PureWick external catheter system 
including the low-pressure suction pump might be helpful for you to use at night, the cost of it is not covered 
by Medicare because the PureWick external catheter system does not meet the definition of DME, and the 
pump is only used with the non-covered disposable PureWick system. Based on this information, we decided 
that Medicare rules for coverage of a Purewick catheter system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Purewick catheter system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test kits and sales tax purchased on December 
20, 2021, and December 21, 2021. 
 
You asked the Plan to pay for the COVID-19 test kits and sales tax. You say that you would like to be 
reimbursed for these test kits. The Plan denied your request. The Plan says both test kits were purchased prior 
to the April 4, 2022, initiative effective date. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and sales taxes 
are included in the calculation of the Medicare fee schedule. The COVID-19 test kits are an OTC item. The 
Plan does not offer a supplemental benefit covering this service, as this is not currently required by Medicare. 
However, for future purchases, these can be obtained with participating providers and covered by Original 
Medicare when using your Medicare card rather than your Plan card. Neither Medicare, nor your Plan, 
currently offers reimbursement of purchased COVID-19 tests. Therefore, we decided that the Plan does not 
have to pay for the COVID-19 test kits and sales tax purchased on December 20, 2021, and December 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it was medically necessary for the 
enrollee to have the services rendered. You also say you are aware a referral was not obtained. The Plan denied 
your request. The Plan says the rendering provider is out-of-network, and no prior authorization was obtained 
for the services rendered to the enrollee. The Plan also says that the documentation does not show that the 
services were urgent or emergent. 
 
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 a domiciliary or rest home visit provided on March 28, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted case management provided on March 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for targeted case management. You say that a representative from the Plan said that 
services for this procedure code did not require authorizations. The Plan denied your request. The Plan says the 
facility and the attending physician are non-participating providers with the Plan. The Plan also says that they 
did not authorize any services for the facility or the attending physician. 
 
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 targeted case management provided on March 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75716 and 36200 billed for date of service 
March 14, 2022. 
 
You asked the Plan to pay for procedure codes 75716 and 36200. The Plan denied your request. The Plan says 
payment for codes 75716 and 36200 is bundled into payment for code 37221.  
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, we have confirmed that codes 
75716 and 36200 are column II codes to column I code 37221. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 75716 and 36200 billed for 
date of service March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that you have a medical 
necessity for the requested CGM and supplies, due to other general symptoms and signs. The Plan denied your 
request. The Plan says you do not meet authorization criteria for the requested CGM and supplies. 
 
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 and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an appeal for LTACH 
admission. The Plan denied your request. The Plan says the service requested is not supported based on the 
records we received. 
 
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 has a history of chronic obstructive pulmonary disease who presented to 
the emergency department on August 30, 2022 with increased shortness of breath and left lower extremity 
weakness since COVID-19 diagnosis in April 2022. The enrollee was admitted and treated with intravenous 
antibiotics. They required bilevel positive airway pressure (BiPAP) until September 9, 2022 when the enrollee 
was maintained with heated hi flow oxygen alternating with BiPAP. By September 14, 2022 the enrollee 
required BiPAP only in post meridiem and was stable for discharge with continued supplemental oxygen 
therapy.  There is no documentation provided indicating medical necessity for admission to a LTACH. You are 
receiving the appropriate care at the present acute care hospital. You do not require services at the LTACH that 
are not available at the acute care hospital. 
 
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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (84443, 83540, 82728, 85025) provided 
on March 8, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 laboratory services (84443, 83540, 82728, 85025) 
provided on March 8, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar 
spine without contrast. 
 
You asked the Plan to pre-approve an MRI scan. You say that it is medically necessary for the enrollee to get 
an MRI scan. The Plan denied your request. The Plan says the enrollee did not complete six weeks of provider 
directed treatment to be completed, with supported treatments including drugs for swelling or pain, an in-office 
workout (physical therapy), and/or oral or injected steroids; therefore, the MRI scan 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 an MRI scan. Our reviewer says that 
the MRI of the lumbar spine without contrast is not medically needed at this time. Our physician reviewer 
found that the enrollee was being treated for radiculopathy of the lumbar region; sciatica, left side; and 
unspecified abnormalities of gait and mobility. The enrollee presented with a shock-like pain down the left leg, 
with reported increasing weakness of the left foot. The exam reveals a normal gait. There is weakness in toe 
extension. The enrollee cannot walk on their heels. There are no reflexes in the legs. 
 
  However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. The documentation does not clearly detail objective 
findings of severe and/or progressive neurological abnormalities. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested imaging in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine without contrast.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 9, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says medical records 
were not received. 
 
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. 
 
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 the lab services provided on November 
9, 2021. have been met. Medical records were not submitted by the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on November 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay at a skilled nursing facility 
from April 1, 2022, to April 18, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay at a skilled nursing facility. You say that you 
should not be billed for the accumulated extra days as they were caused by other medical problems, and you 
were delayed in rehabilitation. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $188 
copayment for each day for day(s) 21-100 in a network skilled nursing facility.  
 
 
  You have been asked to pay a total copayment of $1,316 for the skilled nursing facility stay. You were first 
admitted on March 11, 2022, for three days, and re-admitted on March 25, 2022, for 24 days. The skilled 
nursing facility stay was a total of 27 days and the copayment applied for the last 7 days. 
 
Dates of Service Days Copayment Per Day Member Liability 
March 11, 2022, to March 14, 2022, 
and March 25, 2022, to April 10, 2022 
1-20 $0/day $0 
April 11, 2022, to 
April 18, 2022 
21-27 $188/day $1,316.00 
TOTAL:   $1,316.00 
 
An inpatient stay at a skilled nursing facility 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 an in-patient stay at a skilled nursing facility 
from April 1, 2022, to April 18, 2022. 
 
Your complaint about the rehabilitation taking longer than expected due to additional medical problems caused 
while at the facility is not a valid appeal for medical coverage. This part of your complaint is a grievance that 
must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and supplies. You say that the enrollee is 
presenting episodes of hypoglycemia and hyperglycemia. She has been to the emergency room on several 
occasions for hypoglycemia episode and altered mental status. The use of the device is recommended for better 
control of her type 2 diabetes. The Plan denied your request. The Plan says the enrollee does not meet 
authorization criteria. 
 
 
 
 
 
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 2 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology procedures provided on May 11, 2022, by an 
OON provider. 
 
You asked the Plan to pay for pathology procedures. You say that you are requesting reconsideration because 
the doctor's office failed to send a preauthorization form for approval. 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 pathology procedures provided on May 11, 2022, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visits (99214 x 2) and the 
chiropractic manipulative treatment (98942 x 2) rendered by the out-of-network (OON) provider from  
January 19, 2022, through May 2, 2022. 
 
You asked the Plan to issue reimbursement 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 services were 
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to issue reimbursement for the office visits (99214 x 2) and the chiropractic manipulative 
treatment (98942 x 2) rendered by the out-of-network (OON) provider from January 19, 2022, through May 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
January 12, 2022. 
 
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says refractions are not a 
covered service under your vision benefits. 
 
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 looked at the file and the Plan's rules. The record shows that you received an exam and refractions from an 
ophthalmologist, and Original Medicare does not cover eye refractions. Based on this information, we decided 
that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does 
not have to pay for the determination of refractive state (92015) provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0481) provided January 18, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that definitive urine drug testing may be reasonable and 
necessary based on patient specific indications, including historical use, medication response, and clinical 
assessment, when accurate results are necessary to make clinical decisions. The clinician's rationale for the 
definitive drug testing and the tests ordered must be documented in the patient's medical record. 
 
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 drug testing. Our reviewer says that this 
service was not medically necessary. Our physician reviewer found the records do not document a rationale for 
the necessity of definitive urine drug testing in this case. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing (G0481) provided January 18, 2022.