Persius/hicric huggingface dataset:
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intense therapy from multiple 
disciplines to maximize functional independence with self-care. The Plan denied your request. The Plan says 
that the member's nursing, medical management and rehabilitation needs do not require an interdisciplinary 
team approach to delivery of rehabilitation 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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for leg weakness and 
falls. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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 
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), bifocal lens (V2200), and 
photochromatic tint (V2744) provided on December 16, 2021. 
 
You asked the Plan to pay for the glasses. You say that you would like to be reimbursed the $150.00. The Plan 
denied your request. The Plan says you have exceeded the calendar year maximum for this benefit. 
 
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 one pair of standard eyeglasses or contact lenses every calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you received a pair of eyeglasses on 
November 23, 2021, and your eyeglass benefit has been exhausted. Based on this information, we decided that 
the Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan does not 
have to pay for the frames (V2020), bifocal lens (V2200), and photochromatic tint (V2744) provided on 
December 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from March 4, 2022, to March 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that when a patient is 
in an outpatient facility setting receiving observation care the facility should bill accordingly, and physicians 
should bill matching outpatient observation codes. 
 
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 argues that the enrollee was under outpatient status. However, the 
episode of care summary states that the enrollee was admitted as an inpatient on March 4, 2022, and discharged 
as inpatient to home health on March 5, 2022. Additionally, the order record shows that there was an inpatient 
admission order with an expected stay of two or more midnights. The Plan has not provided documentation to 
support its denial. Therefore, we decided that the Plan has to pay for the services provided from March 4, 2022, 
to March 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 Day sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the Medicare rules 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 enrollee is not adjusting their insulin doses based on their blood 
glucose readings. Based on this information, we decided that Medicare rules for coverage of the sensor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14 Day 
sensor.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that RFA is medically necessary. The Plan denied your 
request. The Plan says that an RFA procedure of the sacroiliac (SI) joint does not meet the Plan's Medical 
Policy coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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. Our reviewer says that the 
requested RFA is considered medically reasonable and necessary in this case. Our physician reviewer found 
that you have chronic sacroiliitis. You have had RFA of L5 and S1 on December 23, 2020, which gave you 
90% pain relief. The pain relief continues at 50%. The request is to repeat the RFA of the L5 facet and S1. 
 
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 have been met. Therefore, we decided that the Plan has to pre-approve 
RFA.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you cannot afford this bill so it 
should be waived. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $100 
copayment per day for a Medicare-covered ultrasound.  
 
You have been asked to pay $98.58 which is less than the standard $100 copayment for an ultrasound. 
Ultrasounds fall 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 an ultrasound provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vascular procedure. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 The Plan follows Medicare rules. Medicare rules say that varicose vein surgery is covered for the indications 
established in the applicable LCD. 
 
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 procedure. Our reviewer says that 
the requested services are not medically reasonable and necessary. Our physician reviewer found that the 
record indicates that the enrollee has painful varicosity of the left leg. The record provided does not indicate the 
failure of a conservative therapy trial. The elements of the coverage criteria are not satisfied. 
 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vascular procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on March 25, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you were never told about the 
copayment so it should be waived. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $150 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  
 
 You have been asked to pay $150 copayment for an endoscopy. Endoscopys fall within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an endoscopy provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
January 9, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that this claim was billed correctly, 
and these codes should be paid. The Plan denied your request. The Plan says procedure codes 99100 AND 
99140 are considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
28, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you feel its inappropriate to 
be billed for this since you were being treated for COVID-19. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 
 
 You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services billed for services provided on 
September 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the codes 
cannot be verified. 
 
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 14020 is adjacent tissue transfer or rearrangement, scalp, 
arms and/or legs; defect 10 sq cm or less. We find that CPT code 1420 is not supported in the medical record. 
The records do not show that adjacent tissue was transferred for the procedure. We find that CPT code 35701 
was billed with a -59 modifier. The medical records provided do not show that the service billed with the -59 
modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the surgery services billed for services provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
10, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you feel its inappropriate to 
be billed a copayment as you were being treated for COVID-19. The Plan denied your request. The Plan says 
the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 
 
 You have been asked to pay $45 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vitrectomy chair. 
 
You asked the Plan to pre-approve the Vitrectomy chair. You say that you are having surgery and need a 
special chair. The Plan denied your request. The Plan says the Vitrectomy chair is considered a convenience 
item and is not primarily medical in nature. 
 
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 Vitrectomy chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95923 billed for date of service January 19, 
2022. 
 
You asked the Plan to pay for procedure code 95923. You say that the medical records show the necessity for 
this service. The Plan denied your request. The Plan says procedure code 95923 is not supported in the medical 
record. 
 
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 95923 is testing of autonomic nervous system function; 
sudomotor including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic 
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential. 
 
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 procedure code 95923. Our reviewer says that procedure 
code 95923 is not supported in the medical record. Our reviewer found the medical record does not include 
documentation of autonomic nervous system function testing.  The reviewer could not cite to a report as this procedure was not found in documentation. Per Codify "In this procedure, the provider tests the sudomotor 
function of the autonomic nervous system to check functioning of nerves that supply sweat glands. The 
autonomic nervous system is that part of the nervous system that controls the blood pressure, pulse rate, 
sweating, and many other bodily functions". 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95923 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95923 billed for date of service January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the PCP would not authorize this visit. You also say 
that the enrollee has no way to pay for the visit. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit 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 the Freestyle Libre 14 Reader device. 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says the Medicare rules 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 enrollee is not adjusting their insulin doses based on their blood 
glucose readings. Based on this information, we decided that Medicare rules for coverage of the device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14 Reader 
device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SmartPill gastrointestinal monitoring system (CPT code 
91112). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are considered experimental and investigational. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while SmartPill is Food and Drug Administration (FDA) approved, more conventional motility 
studies and imaging should be pursued in evaluation of your nausea and early satiety. It should be noted that no 
gastric emptying scan results were provided for this review to document high likelihood of symptomatic 
gastroparesis in your case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SmartPill gastrointestinal monitoring system (CPT code 91112).