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

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are bed ridden and cannot move or do anything 
on your own. You say that you need help as soon as possible because you are currently in a bad condition and 
in pain. The Plan denied your request. The Plan says that an SNF admission is not medically necessary, and 
your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee has functional impairments and medical status change that would 
require skilled therapy and skilled nursing. Evaluating therapists and home health therapists recommend daily 
skilled therapy in a SNF thus daily skilled services in a SNF is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Reader Device. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 Reader Device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the beneficiary does not use insulin with at least three 
daily injections. 
 
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 2 Reader Device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 Reader Device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Continuous Glucose Monitor (CGM) and Supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the beneficiary does not 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 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 supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Continuous Glucose Monitor (CGM) and 
Supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
28, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like this claim reprocessed and 
approved for payment. 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 September 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 29, 2022, to 
July 28, 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 June 29, 2022, to July 
28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve continuous positive airway pressure (CPAP) supplies. 
 
You asked the Plan to pre-approve CPAP supplies. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says that they were unable to make a determination within the 
allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence based on Medicare 
criteria to support their denial for the requested CPAP supplies. The file does not show that the Plan made any 
attempts in obtaining medical records for review. It is the Plans responsibility to show that its decision to deny 
coverage is correct. Records from a Plan provider are considered to be within the control of the Plan. In cases 
where the Plan has not supplied records from a Plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a Plans 
failure to obtain records that are within the Plans control. Therefore, we decided that the Plan has to pre-
approve continuous positive airway pressure (CPAP) supplies.  
 
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 procedure code 99203 billed for date of service February 4, 
2022. 
 You asked the Plan to pay for procedure code 99203. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 99203 is bundled into 
payment for code 77263. 
 
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 99203 
is a column II code to column I code 77263. 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 code 99203 billed for date of service February 4, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88365 billed for 
date of service February 25, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88365. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88365. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88365. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88365 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88365 billed for date of service February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass lenses (V2781) provided on March 25, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyeglass lenses. You say that it was medically necessary for you to change 
your eyeglass prescription because you had cataract surgery. You also say that you went to this OON provider 
because they had the cheapest price, and would like to be reimbursed by your insurance plan. The Plan denied 
your request. The Plan says the records received do not indicate that you had an emergent or urgent medical 
condition, or were in need of specialized service(s) that were not available in the Plan's network. 
 
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. The Plan covers these services when they are rendered by a Plan-approved vision care provider. 
 
We looked at the file and the Plan's rules. The record shows that you received the lenses from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglass lenses have 
not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass lenses (V2781) 
provided on March 25, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair (K0005) and accessories 
(K0108x9, E2601, E0973, K0038, E0971, E2613, E0992). 
 
You asked the Plan to pre-approve an ultralightweight wheelchair and accessories. You say that you do not 
agree with the decision because you meet all the criteria for the custom wheelchair. The Plan denied your 
request. The Plan says many of the features requested for this wheelchair are for convenience and outdoor use. 
Medicare covers durable medical equipment (DME) only when needed in the home. You are requesting an 
ultralight wheelchair for community access because you are a college student. 
 The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also say that for equipment to be covered, it must primarily serve 
a medical purpose. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Some items at issue in this appeal do not 
serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-
approve an ultralightweight wheelchair (K0005) and accessories (K0108x9, E2601, E0973, K0038, E0971, 
E2613, E0992).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and panoramic radiographic image (D0330) provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial of dental services 
received. The Plan denied your request. The Plan says your benefit for the requested items or services have 
already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation (D0150) was exhausted on date of service June 17, 
2021, and the panoramic radiographic image (D0330) on July 12, 2021. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation - new or established patient (D0150), and panoramic 
radiographic image (D0330) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve a PET scan of the brain. 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 follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
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 PET scan of the brain. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in such a setting, the initial 
requirement for coverage of this service would not be met or satisfied. Therefore, this request would not be 
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 a PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Romiplostim. 
 
You asked the Plan to pre-approve Romiplostim. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Romiplostim. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the enrollee does not have 
a diagnosis of immune thrombocytopenia (ITP). The review has determined the documentation support that the 
Romiplostim is not medically reasonable and necessary for the patient. The documentation does not support 
that the Romiplostim is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Romiplostim have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Romiplostim.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found you do not require inpatient services to be supervised on bed rest for 36 hours which 
could have safely been completed at a lower level of care such as observation. There was no complication 
related to the surgery or other indication at the time of admission that you would need inpatient services that 
would likely have spanned two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
home ventilator. 
 
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 home ventilator. Our reviewer says 
that the enrollee does not meet criteria for the requested home ventilator. Our physician reviewer found the 
enrollee was hospitalized with a cardiac arrest, and aspiration pneumonia. Arterial blood gas (ABG) test was 
consistent with acute hypercarbic respiratory failure. The enrollee did better at night with BiPAP, and a 
diagnosis of obesity-hypoventilation syndrome (OHS) was made. There is no diagnosis of chronic obstructive pulmonary disease (COPD), neuromuscular disease, or thoracic restrictive disease. There is no ABG done 
while stable and awake to document chronic CO2 retention. If this is confirmed, the enrollee may benefit from 
BiPAP during sleep as an outpatient. Medicare does not cover a home ventilator when used as BiPAP and does 
not cover it for the treatment of OHS. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on October 5, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not self-administer any drugs 
during your hospital stay. The Plan denied your request. The Plan says self-administered drugs are not a 
covered benefit while under an outpatient hospital stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on October 5, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights. 
  
Your complaint about the nursing staff refusing to help you walk 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 4, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
 
 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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service June 4, 2022.