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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 27, 2022, to 
June 29, 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. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 provided with secondary diagnosis code G93.41, described as 
septic encephalopathy. 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 reviewer says that documentation does not support the billed code. 
Our physician reviewer found the enrollee was a then, 94-year-old female with a past medical history of 
dementia, diabetes, and hypertension. She presented with generalized weakness via ambulance from an assisted 
living facility. In the emergency room, she had baseline dementia and intermittent confusion. She was 
discharged back to assisted living where she remained oriented to self only from presentation to discharge. 
There was no clinical or laboratory evidence of metabolic encephalopathy.  
 
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 June 27, 2022, to June 29, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99285) provided on October 24, 
2022. 
 
You asked the Plan to pay for the emergency room visit. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not supported by the documentation provided. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
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 emergency room visit. Our reviewer says that the records 
do not support the code billed. Our reviewer found the provided records do not show medical decision making 
of high complexity. 
 
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 emergency room visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency room visit (99285) provided on October 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on October 13, 2022, billed 
with code 70480. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says code 70480 is bundled into payment of code 
70450. 
 
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 radiology services provided have been 
met. Specifically, we find that this claim is missing a complete Explanation of Benefits for all lines billed on 
the date of service. Therefore, we decided that the Plan does not have to pay for radiological services provided 
on October 13, 2022, billed with code 70480.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service June 9, 2022. 
 
You asked the Plan to pay for procedure code 88321. You say that these services were medically necessary and 
are supported as billed. 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 88321 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 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service June 9, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the urine lab panel provided on June 23, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says that a panel should only 
be billed with one unit of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that a panel should only be billed with one unit of service. 
However, the Plan has not referenced the Medicare rules used to make its decision. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
urine lab panel provided on June 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor 
(CGM) sensor (E2103). 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 CGM sensor. You say that the enrollee is diagnosed 
with diabetes and needs the requested CGM. The Plan denied your request. The Plan says a CGM is not 
covered under Medicare if the enrollee is not on insulin. 
 
 
 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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre Kit 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre Kit 2 continuous glucose monitor (CGM) sensor (E2103).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (code 22869). 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single 
level. You say that the requested insertion of interlaminar/interspinous process stabilization/distraction device 
is medically necessary. The Plan denied your request. The Plan says the requested insertion of 
interlaminar/interspinous process stabilization/distraction device 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 pre-approve insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level. Our reviewer says that the requested insertion of interlaminar/interspinous 
process stabilization/distraction device is not considered medically reasonable and necessary. Our physician 
reviewer found that interlaminar spacer devices are experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; single level have 
not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, 
including image guidance when performed, lumbar; single level (code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultra-lightweight wheelchair (K0005) and 
accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that the enrollee currently is unable to maintain 
appropriate posture during self-propulsion due to poor support/fit in current standard wheelchair The Plan 
denied your request. The Plan says this request is not cannot be approved as the enrollee resides in a long-term 
care facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that 
the Plan does not have to pre-approve the ultra-lightweight wheelchair (K0005) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies coded as T4521 and T4541. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you were told that as long as your 
primary doctor sent over the information then the incontinence supplies would be covered. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies coded as 
T4521 and T4541.
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 the enrollee was started on bipap without 
any significant improvement and was eventually intubated for hypercapnic respiratory failure. She had to have 
a trach and peg placed due to developing pneumonia and ARDS as well. She was transferred to the long-term 
acute care hospital for vent weaning and therapy. She remained on the vent for quite some time. She is now 
requiring NIV therapy at night as well as prn for daytime use. The Plan denied your request. The Plan says the 
enrollee does not fulfill Medicare criteria for medical necessity. 
 
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 the service is not medically necessary. Our physician reviewer found the enrollee was hospitalized in 
December with acute respiratory failure, requiring intubation and eventually tracheostomy. The enrollee 
developed infectious complications including pneumonia, and ARDS. The enrollee has very severe obesity 
with a BMI of 73, and most likely has obesity hypoventilation syndrome. The enrollee is also on chronic 
narcotics for pain. There does not appear to be a diagnosis of COPD, and there is no diagnosis of thoracic 
restrictive disease or neuromuscular disease. This enrollee may benefit from BiPAP during sleep. If the 
enrollee does have significant COPD, the AVAPS mode can be provided via BiPAP.  Medicare does not cover 
a home ventilator in the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP. 
 
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).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Kit 2 continuous glucose monitor 
(CGM) sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre Kit 2 CGM sensor. You say that the enrollee is diagnosed 
with diabetes mellitus and needs the requested CGM. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for approval of the requested CGM. 
 
 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 or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre Kit 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre Kit 2 continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight test (81479) provided on October 13, 2022. 
 You asked the Plan to pay for the GeneSight test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says there is no documentation that the clinician has made an initial personalized 
decision for the enrollee based on the criteria listed in the LCD. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met.  
 
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 GeneSight test. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that based on review the records provided 
it is noted that this enrollee does have a diagnosis of Major Depressive Disorder, Recurrent, Moderate (F33.2) 
and Mixed Anxiety Disorder (F41.3), a condition that meets the Medicare coverage criteria for the GeneSight 
Psychotropic Assay. This enrollee has not responded to at least one other medication which is noted in the 
record to be Paxil. Documentation showed that this enrollee was tried on Cymbalta and BuSpar for 
augmentation. It does appear that the GeneSight Psychotropic Assay is considered medically necessary and 
reasonable in the treatment of this enrollee. 
 
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 GeneSight test have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneSight test (81479) provided on October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that this device 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 items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the powered upper extremity orthosis. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long term outcomes for this patient. 
 
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 powered upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99285) on June 24, 2022. 
 
You asked the Plan to pay for an emergency department visit. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare-approved amount for these 
procedures includes payment for certain services related to the surgery when furnished by the physician who performs the surgery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an emergency department visit have not been met. Specifically, the case record supports that the 
services at issue were related to a surgical service billed for the same date of service and furnished by the 
physician who performed the surgery. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit (99285) on June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you feel you should qualify for these benefits. 
The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for SNF services provided from October 6, 
2022, to October 31, 2022. 
 
You asked the Plan to reduce the copayment for SNF services. You say that you should not be responsible for 
the SNF copayment past the requested discharge date of October 27, 2022. 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 $0 
copayment per day for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay a $940 copayment for SNF services ($188 per day x 5 days = $940). This 
item/service falls within the SNF care 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 reduce the copayment for 
SNF services provided from October 6, 2022, to October 31, 2022.  
 
Your complaint about the facility not discharging you in a timely manner is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.