Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve the office visit. The Plan denied your request. The Plan says that the Plan 
does not cover out-of-network services rendered with the exceptions of the following: 
 Emergency care or urgently needed services that you get from an out-of-network provider. This includes 
worldwide coverage if covered by your plan. 
 If you need medical care that Medicare requires our plan to cover and providers in our network cannot 
provide this care, you can get this care from an out-of-network provider. For these types of referrals you must 
obtain authorization before seeking care. Your PCP can assist you with obtaining authorization. In this 
situation, we will cover these services as if you got the care from a network provider. If you do not have a prior 
authorization before you receive services from an out-of-network provider, you may have to pay for these 
services yourself. 
 Renal dialysis services when you are temporarily outside the service area, or when prior authorized. 
 
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies. You 
say that it is very difficult to prick you fingers to test your blood sugar. You also say that the monitor continues 
during your sleep to test sugar levels. The Plan denied your request. The Plan says you do not require insulin 
three or more times daily. 
 
 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 continuous glucose monitor (CGM) and supplies. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch and cane holder. 
 
You asked the Plan to pre-approve the crutch and cane holder. You say that you want to appeal the denial. The 
Plan denied your request. The Plan says the crutch and cane holder remain denied. The Plan also says the 
power wheelchair and remaining accessories have been approved. 
 
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 crutch and cane holder.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug is medically necessary for the 
treatment of the enrollee's condition. The Plan denied your request. The Plan says the requested drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Aranesp. Our reviewer says that the 
requested drug, Aranesp, is not medically necessary. Our physician reviewer found there was no documentation 
of iron studies to support that the enrollee's levels meet the guidelines. The reviewer also found that there is no 
documentation to support that at last 2 more months of chemotherapy is planned. Therefore, the reviewer found 
that the requested drug 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bluetooth mouse (E2599) for a speech generating 
device. 
 
You asked the Plan to pre-approve the Bluetooth mouse. You say that this accessory is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that alternative input devices are covered when a 
beneficiary is unable to use standard input devices. Claims for alternative input devices for beneficiaries who 
are able to use standard input devices will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The records do not document any reason the enrollee cannot use the 
standard input device. Based on this information, we decided that Medicare rules for coverage of the Bluetooth 
mouse have not been met. Therefore, we decided that the Plan does not have to pre-approve a Bluetooth mouse 
(E2599) for a speech generating device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97811, 97813) 
provided on October 3, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the supplemental acupuncture benefit for these services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan provides supplemental coverage for 15 
acupuncture visits per year. You received 15 visits for acupuncture treatments for the 2022 calendar year that 
were paid for by the Plan. Therefore, you have exhausted the allowable benefit for these services. Therefore, 
we decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97811, 97813) 
provided on October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes E2300, E2377, and E2313. 
 
You asked the Plan to pre-approve procedure codes E2300, E2377, and E2313. You say that the requested 
accessories are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 
power seat elevation system is not covered as it does not have a medical need. The Plan also says that the 
expandable controller, harness and electronic connector are 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 pre-approve E2300, E2377, and E2313. Our 
reviewer says that the requested electrical accessories are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided documentation indicates that the enrollee has use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Therefore, the reviewer found that the requested electrical accessories are not medically reasonable 
or 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 E2300, E2377, and E2313 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve procedure codes E2300, E2377, and E2313.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a group 3 power wheelchair with options/accessories. 
 
You asked the Plan to pay for the wheelchair. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair 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 pay for the wheelchair. Our reviewer says that the 
requested group 3 power wheelchair with power options/accessories is not medically reasonable and necessary. 
Our physician reviewer found that the provided records from the face-to-face examination with the enrollee's 
physician do not support that the enrollee has a musculoskeletal condition or the presence of a cast or brace 
which prevents 90-degree flexion at the knee, or that the enrollee has significant edema of the lower extremities 
that requires an elevating leg rest. The requested power seat elevation feature is statutorily non-covered as it serves no primary medical purpose. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pay for a group 3 power wheelchair with options/accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 reader. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 reader. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Freestyle Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 reader.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can get the services they need in another setting. 
 
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 is improving but still is unstable and only requires short-term acute 
care at the current facility until they are more stable. The enrollee does not require services at the LTACH that 
are not already available at the current facility. 
 
   
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 LTACH services.
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 attending rehabilitation would help you to be more 
independent and allow you to live with more confidence. The Plan denied your request. The Plan says the IRF 
care is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 documentation does not indicate that the enrollee has an acute illness but 
requires increased help with self-care tasks and mobility. In this case, the complexity of the enrollees nursing, 
medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation does not 
support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81321) provided on June 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81321) provided on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 8, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 8, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services on August 14th, 2022. We decided that the Plan does not 
have to pay for the services on August 15th, 2022.  
 
You asked the Plan to pay for subsequent hospital care (procedure code 99233) provided to the enrollee from 
August 13, 2022, to August 15, 2022.. You say that this should be paid for. The Plan says that the documents 
do not support this level of care. 
 
We decided that the Plan has to pay for the services on August 14th, 2022.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for CPT 99233 on August 14, 2022. Our reviewer says 
that the records supports the use of this code, as 2 of the key elements have been met. The medical record 
supports a detailed interval history and a detailed examination. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services on August 14th, 2022.  
 
We also decided that the Plan does not have to pay for the services on August 15th, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 for CPT 99233 on August 15, 2022. Our reviewer says 
that this code is not supported for this date. The progress note for this visit does not contain a detailed interval 
history and medical decision making of high complexity. There is a more appropriate code for the subsequent 
inpatient care documented on this date of service. 
 
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 on August 15th, 2022 have not been met. Therefore, we decided 
that the Plan does not have to pay for the services on August 15th, 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 87150-91, 87481, 87653, 87798-91, and 
87500-91 billed for date of service June 29, 2022. 
 
You asked the Plan to pay for procedure code 87150-91, 87481, 87653, 87798-91, and 87500-91. The Plan 
denied your request. The Plan says the codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 87150-91 is a column II code to column I code 87500. Code 87481 is 
a column II code to column I codes 87801 and 87150. Code 87653 is a column II code to column I codes 87801 
and 87150. Code 87798-91 is a column II code to column I codes 87801 and 87150. Code 87500-91 is a 
column II code to column I code 87150. The codes at issue have 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 87150-91, 87481, 87653, 87798-91, and 87500-
91 billed for date of service June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you would like the non-invasive volume 
ventilator to be approved, as failure to provide a medically necessary device would produce poor outcomes for 
the enrollee. The Plan denied your request. The Plan says the device to assist with breathing (non-invasive 
ventilator) requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
the record indicates that the enrollee has obesity hypoventilation syndrome with restrictive lung disease. The 
record indicates that the enrollee was successfully treated with bilevel positive airway pressure (BiPAP) in the 
hospital. Our reviewer found that the provided primary source documentation does not contain sufficient 
detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a 
BiPAP machine with average volume assured pressure support (AVAPS) capability, and the Plan has indicated 
coverage for such a device is available upon request. Our physician reviewer also found that the elements of the 
coverage criteria are not satisfied, and the requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).