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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 27, 2021, to October 7, 2021. 
 You asked the Plan to pay for the services. You say that the Medicaid State agency (CMA) may file a request 
for an appeal with respect to a claim for items or services furnished to a dually eligible beneficiary only for 
services for which the Medicaid State Agency has made payment, or for which it may be liable. The Plan 
denied your request. The Plan says there was no daily skilled nursing or therapist need. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy 
service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did 
not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 27, 2021, to 
October 7, 2021.
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 admission is medically necessary. The Plan 
denied your request. The Plan says IRF is not medically necessary and your needs can be met at a lower level 
of care, such as a skilled nursing facility. 
 
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 that while you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program, such as 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 19, 2021, to November 23, 2021. 
 You asked the Plan to pay for the services. You say that the Medicaid State agency (CMA) may file a request 
for an appeal with respect to a claim for items or services furnished to a dually eligible beneficiary only for 
services for which the Medicaid State Agency has made payment, or for which it may be liable. The Plan 
denied your request. The Plan says clinically, the enrollee's condition no longer required daily skilled services 
at an inpatient skilled nursing facility (SNF) 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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided, there 
is no documentation that the patient required skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse were not required to safely and effectively provide medically 
necessary and reasonable treatment from November 19, 2021 through November 23, 2021. The records did not 
document the need for intravenous medications, new tube feeding or ostomy care or daily complex wound care. 
Daily skilled services were not required (or provided) from November 19, 2021 through November 23, 
2021. This patient did not require the services on an inpatient basis, only in a skilled nursing facility 
setting. Services in the nursing facility appear custodial with provision of part time therapy services in this case 
from November 19, 2021 through November 23, 2021. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 19, 2021, to 
November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information that was sent does not support the need for the requested imaging. 
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the computed 
tomography (CT) scan of the head in October 2021, which was unremarkable. In general, neuroimaging is not 
recommended for use in routine headaches in the absence of other neurological signs and/or symptoms. No 
neurological symptoms were identified in this case (no focal findings on examination). There was no indication 
of a change in headache pattern or nature. The enrollee did not have any specific underlying conditions for 
which the presence of headache otherwise generally warrants advanced imaging in clinical practice. Given the 
absence of "red flag" or "yellow flag" findings, the requested service cannot be said to be reasonable and 
necessary for the patient at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the limited abdominal ultrasound 
provided on January 5, 2022, billed with code 76705. 
 
You asked the Plan to pay for the ultrasound interpretation. You say that the records show that multiple exams 
were provided on this date of service. This means they should be paid regardless of how the services were billed. The Plan denied your request. The Plan says the Column 2 code was not billed with a required modifier 
to allow payment. 
 
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 code 76705 
is a column II code to column I code 93976. 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 the interpretation of the limited abdominal ultrasound provided 
on January 5, 2022, billed with code 76705.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supples. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections and 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
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 CGM and 
supples have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath sling. 
 
You asked the Plan to pre-approve a bath sling. You say that you cannot sit up on your own. The Plan denied 
your request. The Plan says it is not for a medical problem. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bath sling.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transthoracic echocardiogram (TTE) with 
doppler provided on December 7, 2021. 
 
You asked the Plan to waive the copayment for the TTE with doppler. You say that you went to a walk-in 
clinic and do not know why you were charged. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $100 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.  
 
You have been asked to pay a $100 copayment for the TTE with doppler. The TTE with doppler falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a transthoracic echocardiogram (TTE) with doppler provided on 
December 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found the case file does not contain documentation of 
trial and failure of Orthovisc, Synvisc or Synvisc-One or that Orthovisc, Synvisc or Synvisc-One would likely 
be less effective, and/or would likely have adverse effects for you 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable, walk-in, Whirlpool tub (K1003). 
 
You asked the Plan to pre-approve the walk-in tub. You say that you do not always have someone to assist you 
with getting in and out of the shower. This is personal and you would like to be able to bathe yourself without 
assistance. The Plan denied your request. The Plan says this item is not a covered Medicare benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the portable, walk-in, Whirlpool tub (K1003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
services are not separately billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. Supplies for a continuous glucose monitor was requested using codes 
A9276, A9277, and A9278. The supply allowance for supplies used with a CGM system (K0553, A4238) 
encompasses all items necessary for the use of the device. Based on this information, we decided that Medicare 
rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continuous glucose monitor supplies.
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 you did not expect your surgery to be this severe, so 
the Plan should approve this therapy. The Plan denied your request. The Plan says the denial of authorization 
for IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need 
physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you will be able to fully participate in - or 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 transfer to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve this transfer. You say that SNF services are medically necessary for the
enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a transfer to SNF care. Our physician
reviewer says that the medical records show the enrollee is a 71-year-old woman with a history of
hypertension, degenerative joint disease, thyroid disease, and depression, who suffered a stroke and was
admitted to the hospital on April 28, 2022. The medical records on May 17, 2022, indicate that the enrollee
requires moderate assist for transfers and is unable to ambulate. Our reviewer says that the documentation does
not support that the enrollee in this case requires services at a SNF that are not available at the acute care
setting where she is currently receiving care. Consequently, the requested SNF services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee currently.
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 skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that these services should be covered because 
you do not want to be set back and feel you are not improving at home. The Plan denied your request. The Plan 
says additional physical therapy is not medically necessary in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the health plan. You have had 
extensive prior therapy, and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment or that the services can only be safely and 
effectively performed only by a therapist or by or under the supervision of a therapist. The requested services 
are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain your current condition or to 
prevent or slow further deterioration. There has been instruction in an independent home program. You are not 
showing regression of strength with less frequent visits. You were noted as likely needing a left total knee 
arthroplasty in the future. You were encouraged to strengthen at home including hip flexion and quadriceps. 
Although hip flexor/quad weakness is limiting your right lower extremity movement in/out of car and on/off 
bed, you are noted to be maintaining well independently with the home exercise program. Ongoing skilled 
therapy is not 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 15 additional physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 13, 
2022. 
 
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 an appropriate modifier was not billed with this edit. 
 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 code 76376 
is a column II code to column I code 78226. 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 imaging services provided to the enrollee on January 13, 2022.