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

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM) includes all supplies and accessories, 1 month supply (K0553) provided October 29, 2021. 
 
You asked the Plan to pay for the supply allowance for the therapeutic CGM. You say that please review the 
attached medical records The Plan denied your request. The Plan says evidence of misrepresented services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code K0553 is Supply allowance for therapeutic continuous 
glucose monitor (cgm), includes all supplies and accessories, 1 month supply. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the supply allowance for CGM. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our reviewer 
found based on the medical records provided there is no documentation that the provider discussed the need for the billed supply code (K0553 supply allowance for therapeutic continuous glucose monitor, includes all 
supplies and accessories, 1 month supply); therefore the billed supply code cannot be verified. 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the supply allowance for the therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM) includes all supplies and accessories, 1 month supply (K0553) provided October 29, 2021.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says SNF care is not medically necessary and the patient can receive skilled services on 
an intermittent outpatient basis. 
 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 daily 
skilled services are not necessary. Our physician reviewer found this patient has a history of heart disease, 
chronic obstructive pulmonary disease, colon cancer, morbid obesity, diabetes, hypertension, osteoarthritis, and 
urinary tract infection. The patient was hospitalized from March 11, 2022, to March 14, 2022. The patient was 
then admitted to swing bed status post-acute hospitalization after recurrent falls and failed discharge home from 
March 23, 2022, to March 31, 2022, which is the date of the discharge summary. According to the 
Occupational therapy plan of care, the patient had a poor rehab potential.  However, the patient has a good 
rehab potential under the physical therapy plan of care. The patient does not require skilled nursing services but 
does have skilled therapy needs. However, the documentation does not support that it is medically reasonable 
and necessary to provide skilled therapy services on a daily basis on 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 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 the services (99100) provided on May 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of B under the 
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into 
payment for other services. No separate payment can be made for the anesthesia services (99100).  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 the services (99100) provided on May 28, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
October 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 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 pay for the services provided by an out-of-network provider on October 
15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 19, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that you do not drive any more, and this eye clinic is 
close to your home so you can walk to the office. The Plan denied your request. The Plan says the provider is 
not participating with the Plan's vision provider. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision 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 file shows that the eye exam was not provided by the Plans 
vision network provider. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on October 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the 
shoulder (73221). 
 
You asked the Plan to pre-approve an MRI scan of the shoulder. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
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 of the shoulder. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of an adequate trial and failure of physical therapy for shoulder 
pain. There are no red flags necessitating an MRI scan 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 an MRI scan of the shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the shoulder (73221).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the provider of service nor the referring provider in this case is a network provider with the Plan. 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 medical services provided 
on July 1, 2021, by an out-of-network (OON) provider.
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 the enrollee needs continuous physical therapy and 
occupational therapy. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
SNF care does not meet the requirements for approval. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring services (95907, 95885, 95885, and 95999) 
provided on May 6, 2021. 
 
You asked the Plan to pay for codes 95907, 95885, 95885, and 95999. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We 
looked at the file and Medicare rules. In this case, the review shows that codes 95907, 95885, and 95885 were 
not billed with modifier 26 per Medicare guidelines.  
 
Medicare rules also say providers must report services with the appropriate CPT code. In this case, the CPT 
Code Manual definition of code 95999 is Unlisted neurological or neuromuscular diagnostic procedure. We 
find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of 
four testing was performed, and this is not the appropriate code for this service. Per Medicare guidelines, it is 
inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. 
There is no separate code for train of four monitoring.  
 
Based on this information, we decided that Medicare criteria have not been met for the billing of codes 95907, 
95885, 95885, and 95999. Therefore, we decided that the Plan does not have to pay for the monitoring services 
(95907, 95885, 95885, and 95999) provided on May 6, 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 you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the requested IRF care. 
 
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 you are medically stable, with no new medical issues and do not need PM&R 
physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions.  At the current functional level with debility, you are not 
likely to make a significant functional recovery in an IRF. Your rehab can be safely provided at a lower 
intensity and alternate setting such as in the current facility with intermittent therapies. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the services (99497) provided on April 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99497 is "Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate". 
 
 We find that CPT code 99497 is not supported in the medical record. Specifically, the records do not show the 
time spent on advanced care planning services. This is a time-based code. 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 the services (99497) provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable ramp. 
 
You asked the Plan to pay for a portable ramp. You say you are wheelchair bound and need the portable ramp 
to go into and out of buildings. The Plan denied your request. The Plan says portable ramps are not covered by 
Medicare or the Plan. 
 
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 say that self-help devices are not covered. A portable ramp 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. Therefore, we decided that the Plan does not have to pay for a portable ramp.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve provide coverage for an out of network provider. 
 
You asked the Plan to pre-approve the requested out of network provider. . You say that you prefer to see the 
requested provider. The Plan denied your request. The Plan says that there are providers in network who can 
provide this treatment. 
 
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 failed to provide a copy of the 2022 Evidence of 
Coverage. The Plan provided a copy of last years 2021 Evidence of Coverage. Therefore, we decided that the 
Plan has to pre-approve provide coverage for an out of network provider.  
 
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 adjust the copayment for the arthrocentesis, aspiration and/or 
injection, of a major joint or bursa; without ultrasound guidance (20610), and the fluoroscopic guidance for 
needle placement (77002) provided on November 16, 2021. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $175 copayment for Medicare-covered 
radiological diagnostic services, not including x-rays, performed in a physicians office or at a free-standing 
facility. Additionally, you must pay a $50 copayment for services obtained from a specialist, or under certain 
circumstances, treatment by a nurse practitioner or physicians assistant or other non-physician health care 
professionals in a specialists office.    
 
You have been asked to pay $184.72 ($50 + $134.72). This amount includes a $134.72 copayment for the 
Medicare-covered radiological diagnostic service provided. This is the Plans allowed amount for this service 
which is less than the applicable copayment. Additionally, this amount includes a $50 copayment for the 
injection service provided by a specialist. 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 adjust the copayment for the 
arthrocentesis, aspiration and/or injection, of a major joint or bursa; without ultrasound guidance (20610), and 
the fluoroscopic guidance for needle placement (77002) provided on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77001 billed for date of service August 9, 
2021. 
 You asked the Plan to pay for procedure code 77001. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 77001 is bundled into payment for 
code 77012. 
 
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 77001 
is a column II code to column I code 77012. 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 77001 billed for date of service August 9, 2021.