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

 
We decided that the Plan does not have to pay for the reagent strips for a home blood glucose monitor (BGM) 
provided on October 2, 2021. 
 
You asked the Plan to pay for the regent strips for a BGM. You say that you are appealing the denied service 
with medical records. The Plan denied your request. The Plan says without the proper documentation the 
requested service is not medically necessary. 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the regent strips for a BGM have been 
met. Documentation provided showed the Plan requested medical records multiple times but they were never 
sent or received, without medical documentation there is not sufficient information to determine the medical 
necessary of the services provided. Therefore, we decided that the Plan does not have to pay for the reagent 
strips for a home blood glucose monitor (BGM) provided on October 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on October 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services provided were medically 
necessary and, the records provided support these services. The Plan denied your request. The Plan says there 
is no prior authorization on file for the services rendered. 
 
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 nursing facility care provided on October 13, 
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 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 for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a continuous glucose monitor (CGM) 
have been met. The plan did attempt to get medical records, but none were submitted. The enrollees provider 
should submit supporting medical records to show why this CGM is needed. 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 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 medically necessary to prevent 
infection and further complications. The Plan denied your request. The Plan says the services you need can be 
provided safely in another 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 you do 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 12, 2021, to April 
17, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that you have submitted the proof of timely 
filing. The Plan denied your request. The Plan says the original claim was received on May 10, 2021, and has a 
processed date of September 15, 2021. The Plan also says that the corrected claim was received on October 10, 
2022. This is past the allowed 12-month time frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a corrected claim for inpatient hospital care was not filed until October 10, 2022. This 
means that more than one calendar year from the date of service had passed from the initial determination issue 
date of the original claim. Therefore, we decided that the Plan does not have to pay for inpatient hospital care 
provided from April 12, 2021, to April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames, single vision lenses, and polycarbonate lenses 
provided on October 17, 2022. We also decided that the Plan does not have to waive the copayment for an eye 
examination provided on October 17, 2022. 
 
You asked the Plan to pay for frames, single vision lenses, and polycarbonate lenses. You say that you keep 
getting bills. You also say you paid $45, but the provider is still asking for $15. The Plan denied your request. 
The Plan says you had already reached the $150 eyewear benefit for the 2022 calendar year. The Plan also says 
that the cost sharing for the eye examination was charged correctly. 
 
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 up to $150 per calendar year for eye wear applied at the time of service. The rules 
also 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 $15 
copayment for an annual routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that if you choose a Plan Vision Care participating 
provider, you have the benefit of $150 per calendar year applied at the time of service. The Plan rules also say 
that you would be responsible to pay for any remaining balance. The record shows this benefit was exhausted 
with this service on October 17, 2022. You have also been asked to pay a $15 copayment for an eye 
examination. An eye examination falls within the annual routine eye examination 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. Based on this information, we decided 
that the Plan's rules for coverage of an eye examination, frames, single vision lens, and polycarbonate lens have 
not been met. Therefore, we decided that the Plan does not have to pay for frames, single vision lenses, and 
polycarbonate lenses provided on October 17, 2022. We also decided that the Plan does not have to waive the 
copayment for an eye examination provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on October 6, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you feel that you should not 
have to pay the copayment for this visit. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $30 
copayment for each Medicare-covered urgent care facility visit. 
 
You have been asked to pay a $25 copayment for the urgent care visit because the Plan is only holding you 
responsible for this amount, which is less than $30. This item/service falls within the urgently needed services 
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 the urgent care visit provided on 
October 6, 2022.
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 services are necessary because you 
don't want to risk infection and possibly lose your left foot. The Plan denied your request. The Plan says your 
needs can be met at a lower level of care. 
 
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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is still requires, physical and 
occupational therapy, as acute inpatient rehab is the best option for them to return home. The Plan denied your 
request. The Plan says an IRF admission is not medically necessary, and the enrollee can receive the care they 
need in another 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of the chest and a CT scan of the abdomen 
provided on April 27, 2022. 
 
You asked the Plan to pay for the CT scans. You say that you are requesting payment for the services provided. 
The Plan denied your request. The Plan says there were no records showing the scans were medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pay for the CT scans. Our reviewer says that the CT 
scan of the chest and the CT scan of the abdomen were not medically necessary. Our physician reviewer found 
that it is logical to assume the CT of the chest and abdomen done on April 27, 2022, was done for surveillance 
but there is no note describing an order for same and no report of the exams. The report which appears in the 
records is CT of the chest and abdomen of August 8, 2022. That report indicates a comparison to CT of the 
chest and abdomen dated April 27, 2022, but again no report of those 2 exams is in the records. The 
documentation provided does not include the referral nor the reports for the CT exams in question. 
 
  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 CT scans have not been met. Therefore, we decided that the Plan does not 
have to pay for a CT scan of the chest and a CT scan of the abdomen provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic braces (D8090) provided on May 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that the braces were medically necessary, and they 
were not for cosmetic reasons. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the orthodontic braces are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
orthodontic braces (D8090) provided on May 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines the 
inpatient rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for below the knee amputation. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical records support 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 the enrollee 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high noble metal 
tooth #'s 18 and 20 (D6750), and pontic - porcelain fused to high noble metal tooth #19 (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says dental services from an out-of-network provider are not covered by 
your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a retainer 
crown - porcelain fused to high noble metal tooth #'s 18 and 20 (D6750), and pontic - porcelain fused to high 
noble metal tooth #19 (D6240).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring treatment management 
services (99457) provided on July 12, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. The claim image is submitted with 
frequency code of "8" in section 12A of the 1500 Claim Form, which is used to "Void/cancel of prior claim". 
The Plan has already voided/canceled the claim which was submitted initially by the appellant. The appellant 
needs to resubmit claim with correct frequency code. If the provider determines that a billing error occurred 
during the initial submission of the denied claim, the Plan will accept a submission of a corrected claim to 
consider services for payment. Therefore, we decided that the Plan does not have to pay for the remote 
physiologic monitoring treatment management services (99457) provided on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for TENS device, four or more leads, for multiple nerve stimulation 
(E0730) provided on September 16, 2022. 
 
You asked the Plan to pay for the TENS unit. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the denied services are not a covered benefit as there is no evidence to support the 
ordering provider is ordered the service. 
 
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.  
 
We looked at the file and Medicare rules. An order from the rendering provider was submitted for a TENS unit; 
therefore, the durable medical equipment (DME) is supported. Based on this information, we decided that 
Medicare rules for coverage of the TENS unit have been met. Therefore, we decided that the Plan has to pay 
for TENS device, four or more leads, for multiple nerve stimulation (E0730) provided on September 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three additional units of procedure code 99223 rendered on 
May 26, 2022. 
 
You asked the Plan to pay for the additional services. You say that this should be paid for. The Plan denied 
your request. The Plan says the records only document one unit of service being performed. 
 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 additional services. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that the medical record only 
includes documentation of one evaluation and management service. In this case, only one unit of service can 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 additional services have not been met. Therefore, we decided that the Plan 
does not have to pay for three additional units of procedure code 99223 rendered on May 26, 2022.