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

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensors. 
 
You asked the Plan to pre-approve Freestyle Libre 2 Sensors. You say that the enrollee was previously on 
insulin and use of the Plan-approved CGM has allowed her to come off of that medication. You say that the 
records provided support that continued use of the continuous glucose monitor (CGM) and related supplies is 
medically necessary for the enrollee. You say that the enrollee has demonstrated marked improvement with his 
glycemic control from using the Libre 2 technology. The Plan denied your request. The Plan says the criteria 
for coverage have not been met because the enrollee is not taking insulin three times a day. 
 
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 Freestyle Libre 2 Sensors. Our reviewer 
says that Freestyle Libre 2 Sensors are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the Freestyle 
Libre 2 device at issue in this case meets all Medicare criteria for medically reasonable and necessary for the 
patient. Provided records do not document the patient is using an insulin pump or is administering insulin three 
or more times per day  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre 2 Sensors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Freestyle Libre 2 Sensors.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that transfer to another SNF is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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. 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found a SNF-to-SNF transfer is not medically necessary. There is no evidence that the 
enrollee is in need of services that are not currently available 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 91065 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 91065. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 91065 is 2. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE.  
 Based on this information, we decided that Medicare rules for coverage of procedure code 91065 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 91065 billed for date of 
service August 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from July 1, 
2022, to July 29, 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 a corrected claim is needed in order to process the claim. 
 
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 services have been met. The claim 
was not submitted with the correct type of bill. 323 is an invalid bill type. Therefore, we decided that the Plan 
does not have to pay for home health services provided to the enrollee from July 1, 2022, to July 29, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient therapy services provided by a skilled nursing facility 
(SNF) from February 14, 2022, through February 28, 2022. 
 
You asked the Plan to pay for the SNF therapy services. You say that these services are covered by Medicare 
Part B and should not be denied. The Plan denied your request. The Plan says that the claim does not have a 
valid provider type. 
 
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's denial rationale is not sufficiently clear in this case. It is stated that 
the claim is not billed with a valid provider type. No explanation is given to support this. The claim was billed 
by a SNF for outpatient (Part B) therapies. Review of the claim shows appropriate procedure codes and a valid 
type of bill. We find that the denial is not supported. Therefore, we decided that the Plan has to pay for the 
outpatient therapy services provided by a skilled nursing facility (SNF) from February 14, 2022, through 
February 28, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on July 29, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for Ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance transport. This item/service falls within the 
Ambulance services 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 ambulance transport 
provided on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight gene panel provided to the enrollee on July 
14, 2022. 
 
You asked the Plan to pay for the testng. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider ordered this testing but did not specify which medications were being 
considered for treatment. 
 
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 pay for the testng. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not show the severity of the patients depressive illness and there is no 
documentation as to this patient having issues with sleep presently. Based on review of the documentation 
provided, this patient does not meet the criteria for GeneSight Psychotropic Assay and is considered medically 
necessary and reasonable in the treatment of this individual due to severity of symptoms and the patient has not 
been involved with psychotherapy. 
 
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 testng have not been met. Therefore, we decided that the Plan does not have 
to pay for the GeneSight gene panel provided to the enrollee on July 14, 2022.
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 the services 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. 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 enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroiliac (SI) joint injections 
 
You asked the Plan to pre-approve SI joint injections. You say that the enrollee has had at least 75% pain relief 
from the last injection on October 4, 2022. You say that the enrollee has experienced pain relief for 2 months 
and was able to do activities of daily living. You say that the enrollee was able to stand up and move around 
more after the injection. The Plan denied your request. The Plan says that the requested injection services are 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that SI joint injections are covered when 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 SI joint injections. Our reviewer says 
that the criteria for coverage have been met. Our physician reviewer found the enrollee has Left sacroiliitis. She 
underwent a local anesthetic/steroid block and achieved 75% pain relief for 2 months. She also was better able 
to perform her activities of daily living. The request to repeat the block is medically reasonable and 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 SI joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve sacroiliac (SI) joint injections  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to 
April 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to 
April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve RFA services.. You say that the records provided support the need for the 
requested injection services. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
of having completed 2 diagnostic medial branch blocks. 
 
The Plan follows Medicare rules. Medicare rules say that RFA services are covered for certain indications and 
when 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 RFA services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has not had 2 sets of 
diagnostic medial branch blocks, each producing more than 80% pain relief. A second set has not been 
performed and the requested RFA services are not medically reasonable and 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 RFA services. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 23, 2022 to 
March 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 23, 2022 to 
March 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Life2000 system is not medically 
necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD) requiring 
supplemental oxygen, although no pulmonary function tests are provided. There is no arterial blood gas (ABG) 
documenting chronic carbon dioxide (CO2) retention. The Life2000 is not a true ventilator because it is not 
capable of providing full ventilatory support. It is designed to be used during activity. There is insufficient evidence that it is of benefit in the treatment of chronic obstructive pulmonary disease (COPD), or any chronic 
lung disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
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 the services 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. 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. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal crown (D2750) Tooth #23, 27. 
 
You asked the Plan to pre-approve dental services. You say that you were told the requested white glass with 
metal crown (D2750) Tooth 23, 27 is medically necessary. The Plan denied your request. The Plan says the 
requested white glass with metal crown (D2750) Tooth 23, 27 is denied because the x-ray shows a crown is not 
needed to fix your tooth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our physician reviewer 
found the documentation provided did not meet the criteria for coverage for crown restorations (D2750) for 
teeth #'s 23 and 27. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve white glass with metal crown (D2750) Tooth #23, 27.