Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs services that are 
difficult to get outpatient. The Plan denied your request. The Plan says criteria for admission to the LTACH 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can be administered safely at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73600 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the records support the procedure was 
performed. The Plan denied your request. The Plan says a modifier was not billed to represent the services as 
separate/distinct. 
 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 73600 is a column II code to column I code 73610. The records do 
not show that more than one ankle x-ray was provided on the date of service at issue. 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 73600 billed 
for date of service March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression garments identified with code L0982, 
A6534, S8429, and A5510 that were issued on December 8, 2021, to January 18, 2022. 
 
You asked the Plan to pay for the compression garments. You say that you will need these items for the rest of 
your lift because of swelling of the legs. The Plan denied your request. The Plan says compression garments 
are not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that compression garments described by code L0982, 
A6534, S8429, and A5510 are noncovered because they do not meet the statutory definition of a surgical 
dressing. Compression garments for the treatment of lymphedema are not covered.  
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
garments identified with code L0982, A6534, S8429, and A5510 that were issued on December 8, 2021, to 
January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on April 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that this provider has been treating you for 20 
years, and you consider it not convenient for you to change doctors. The Plan denied your request. The Plan 
says the services were not authorized or provided by your primary care physician or by providers within the 
contracted network. 
 
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 items/services at issue in this appeal. 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 a specialist office visit provided on April 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left heart catheterization. 
 
You asked the Plan to pre-approve left heart catheterization. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because coronary computed tomography (CT) angiography or imaging stress test may be an equivalent and 
safer test for the enrollee. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has no history of chest pain. A previous radionuclide stress test was 
negative in the past and has not been repeated. Guidelines do not support a need for cardiac catheterization in 
this 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 left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left heart catheterization.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that it is not safe for the enrollee to go home 
and care for herself. You say that she had a stroke and is unable to walk and needs rehabilitation care before 
going home to care for herself. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for admission to an SNF. 
 
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 the SNF admission. Our reviewer says 
that the enrollee does not have documented skilled therapy needs. The enrollee is ambulating 100 feet and 
tending to assisted daily living skills with minimal supervision. Our physician reviewer found 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. Our reviewer also found that 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a SNF admission.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need rides for 
medical appointments. The Plan denied your request. The Plan says that you have exhausted all 20 trips for the 
benefit year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty (20) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99239 provided on December 13, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation shows 
that another evaluation and management service code 99232 (Subsequent hospital care, per day, for the 
evaluation and management of a patient) was billed by the same provider under claim 820213481474579. This 
means that this code is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the hospital discharge day management services have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital discharge day management services coded 99239 provided on 
December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive PGx panel provided to the enrollee on May 
11, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the comprehensive panel for genotyping of genetic variations that may be linked to 
enhanced/reduced effect or severe side effects of drugs metabolized remains unproven as a screening tool. The 
clinical value and effectiveness of comprehensive pharmacogenetic testing has not been demonstrated in the 
peer reviewed literature. The review has determined that the requested PGx testing medically is not reasonable 
or necessary according to the coverage criteria 
 
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 a comprehensive PGx panel provided to the enrollee on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has failed lower level of care 
multiple times. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
LTACH services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be currently still somewhat unstable and requires short-
term additional acute care services that can be administered safely at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to an LTACH is not medically necessary as the enrollee is not stable 
for transfer yet and as it would not be clinically advantageous. Completion of treatment at the current facility is 
recommended. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the CGM 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 documentation does not indicate that you are insulin-treated with 
multiple daily administrations of insulin or a continuous subcutaneous insulin infusion pump. Based on this 
information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323) and administration (20610). 
 
You asked the Plan to pre-approve Euflexxa injection. You say that the requested drug is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred 
drugs, Orthovisc, Synvisc or Synvisc One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa injection. Our reviewer says 
that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does 
not indicate that the enrollee has tried and failed the required drugs. The reviewer found that there is no 
indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa injection have not been met. Specifically, the file does not indicate 
that the enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to 
pre-approve Euflexxa (J7323) and administration (20610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your doctor is a hospitalist 
physician and depends upon the hospital staff to verify eligibility and to obtain proper authorization from the 
patient's insurance company. The Plan denied your request. The Plan says services from non-participating 
providers are not covered under open access unless preauthorized. 
 
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 items/services at issue in this appeal. 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 subsequent nursing facility care provided on 
February 16, 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 CGM system. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM 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 documentation indicates that the enrollee is not currently insulin-
treated with three or more daily administrations of insulin or a continuous subcutaneous insulin infusion pump. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve CGM system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM system and standard supply allowance. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM 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 documentation does not show that your insulin treatment 
regimen requires frequent adjustments. Based on this information, we decided that Medicare rules for coverage 
of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM 
system and standard supply allowance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fully electric hospital bed received on April 28, 2021. 
 
You asked the Plan to pay for the fully electric hospital bed. You say that the enrollee is in hospice where this 
bed is required. The Plan denied your request. The Plan says the item received is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the fully electric hospital 
bed received on April 28, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from February 9, 2022, through 
February 11, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment based on the NOA having previously been submitted. The Plan denied your request. The 
Plan says that the NOA document is required to process the final claim. 
 
The Plan must follow Medicare rules. Medicare rules say that only one NOA is required for any series of HH 
periods of care beginning with admission to home care and ending with discharge 
 
We looked at the file and Medicare rules. In this case, the Plan has denied payment stating that an NOA is 
required for payment with the final claim. This is incorrect based on the rule changes that took place in 2022. 
An NOA for these dates is not required for payment. Based on this information, we decided that Medicare rules 
for coverage of the home health services have been met. Therefore, we decided that the Plan has to pay for the 
home health services provided from February 9, 2022, through February 11, 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.