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

 
We decided that the Plan does not have to pay for orthoses (L1833, L2397, L2810) rendered on November 23, 
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 the documentation submitted did not sufficiently support the billed supply code. 
 
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 services. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the enrollee has not had recent surgery or a recent injury.  The documentation doesnt 
support that the enrollee had significant symptoms associated with his knee or any abnormal physical findings 
associated with the knee. The requested knee orthosis is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for orthoses (L1833, L2397, L2810) rendered on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service April 4, 
2022. 
 You asked the Plan to pay for procedure code 0003A. You say that the services at issue have been billed 
correctly. 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 0003A 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 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service April 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on September 30, 2022. 
 
You asked the Plan to pay for the supply allowance for CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says a receipt or proof of delivery was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the file did not include a proof of delivery for the supply allowance rendered for the billed date of 
service. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic 
continuous glucose monitor (CGM) provided on September 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on September 1, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the provider should bill the facility. 
 
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. We find that the Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. Though it is true that the TC cannot be 
paid in the facility setting, the documentation shows that only the professional component was billed. The 
services were billed with modifier -26 for the professional component. There is no reason that the professional 
component cannot be paid in the hospital outpatient setting Therefore, we decided that the Plan has to pay for 
imaging services provided on September 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 received on October 18, 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 this testing is not separately billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for procedure code 83789 received on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) provided on 
December 12, 2022. 
 
You asked the Plan to pay for the annual wellness visit (AWV). You say that you were surprised to see this was 
not covered. You say that you switched providers when you were notified that your previous provider was 
leaving your plan. You say that you were not notified this would not be covered. You also say that you cannot 
afford to pay this amount. The Plan denied your request. The Plan says the benefit limit has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) (G0439) 
provided on December 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve quantitative magnetic resonance for analysis of tissue 
composition. 
 
You asked the Plan to pre-approve quantitative magnetic resonance. You say that you are requesting 
reconsideration for the denial of a quantitative MRI based on medical necessity. The Plan denied your request. 
The Plan says that there is not enough evidence showing the requested study would improve the outcome for 
the enrollee's condition. 
 
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 quantitative magnetic resonance. Our 
reviewer says that the service is medically necessary and reasonable. Our physician reviewer found the notes 
describe known fatty liver by ultrasound for the past ten years. There are now physical findings suggestive of 
advancing liver disease. The most recent ultrasound showed a fatty liver with enlargement (18cm). The concern 
is non-alcoholic steatohepatitis (NASH), and the ordered scan would allow a predictive way of anticipating 
accelerating liver dysfunction. This is an accepted way of evaluating the liver rather than being investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of quantitative magnetic resonance have been met. Therefore, we decided that the 
Plan has to pre-approve quantitative magnetic resonance for analysis of tissue composition.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a supracervical hysterectomy procedure (58542). 
 
You asked the Plan to pre-approve a supracervical hysterectomy. You say that a supracervical hysterectomy is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says that the request for a 
supracervical hysterectomy is not medically necessary. 
 
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 a supracervical hysterectomy. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that it is reasonable to manage symptomatic prolapse expectantly or with 
conservative or surgical therapy. Both conservative and surgical treatment options should be offered. There are 
no high-quality data comparing these two approaches. The choice of therapy depends upon the enrollee's 
preferences, as well as the ability to comply with conservative therapy or tolerate surgery. 
 
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 supracervical hysterectomy have been met. Therefore, we decided that the 
Plan has to pre-approve a supracervical hysterectomy procedure (58542).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Buprenorphine patch. 
 
You asked the Plan to pre-approve the Buprenorphine patch. The Plan denied your request. The Plan says 
Buprenorphine patch is a self-administered drug. Based on this information, medication does not fall under Part 
B coverage. 
 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 pre-approve the Buprenorphine patch.  
 
Benefits for the Buprenorphine patch may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 11, 2022, to 
January 18, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the records do not validate the diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with primary diagnosis code A41.9, defined as sepsis, unspecified 
organism; and secondary diagnosis code R65.20, defined as severe sepsis without septic shock. 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 inpatient hospital services at the DRG originally billed. 
Our physician reviewer found that the enrollee presented to the hospital with chest pain and shortness of breath. 
At the time of presentation, his heart rate was 111 bpm and respiratory rate was 30. His oxygen saturations 
were normal on room air. He was admitted for a myocardial infarction and pulmonary edema. There was no 
evidence of life-threatening organ dysfunction due to dysregulated host response to an infection or persistent 
hemodynamic instability. The documentation does not consistently and completely support the assigned 
principal diagnosis code or the secondary diagnosis code with the DRG.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on January 11, 2022, to January 18, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve air ambulance services. 
 
You asked the Plan to pre-approve air ambulance services. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says the request for air ambulance services is not 
medically necessary. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition needs immediate and rapid ambulance transport that could not be provided by ground 
ambulance. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of air ambulance services have not been met. Specifically, the request for transport is to be close to 
family caretakers. Air ambulance services have not been requested for a medical purpose in this case. 
Therefore, we decided that the Plan does not have to pre-approve air ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device (E0676) provided on October 5, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and submitted medical records for review. The Plan denied your request. The Plan says 
pneumatic compression devices are not covered by Medicare when the place of service is an ambulatory 
surgical center. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, you billed with place of service 24, which is an 
ambulatory surgical center. Medicare rules state that for durable medical equipment to be covered, it must be 
appropriate and be needed for use inside the home. Medicare does not consider an ambulatory surgical center a 
home. Therefore, we decided that the Plan does not have to pay for a segmental gradient pressure pneumatic 
appliance, half leg (E0673) and a pneumatic compression device (E0676) provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliances coded E0673 billed for August 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliances coded E0673 billed for 
August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) 
sensor (A9276). 
 
You asked the Plan to pre-approve a Freestyle Libre 3 CGM sensor. You say that you have diabetes and are not 
insulin treated. The Plan denied your request. The Plan says the requested CGM is not a covered benefit 
because it is not classified, nor used with equipment classified, as DME. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM) sensor (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 99601. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service August 24, 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 for the enrollee to make a 
full recovery and return to community. The Plan denied your request. The Plan says ongoing skilled care can 
be provided in an alternative setting. 
 
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit (99212) provided on October 28, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that you did not go to the doctor's office on this date. 
You also say that you did not see this provider. The Plan denied your request. The Plan says prior authorization 
was not obtained. 
 
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 provider in this case is not 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 the telehealth visit (99212) provided on October 28, 2022, by an 
out-of-network (OON) provider.