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

 
We decided that the Plan does not have to pay for an emergency department visit (99285) billed for date of 
service October 21, 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 the available records do not support the reported 
level of care. Procedure code 99284 would be more appropriate. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 an emergency department visit Our reviewer 
says that the code at issue does not meet criteria for payment. Our reviewer found that the provided medical 
records do not support medical decision making of high complexity and that the presenting problem posed an 
immediate significant threat to life or physiologic function. 
 
We looked at this physician's review, 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. Therefore, we decided that 
the Plan does not have to pay for an emergency department visit (99285) billed for date of service October 21, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on June 30, 2022, to July 31, 2022. 
 
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that prior authorization was not obtained. 
 
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. A valid denial reason was not provided for these services. Therefore, we decided 
that the Plan has to pay for inpatient hospital services provided on June 30, 2022, to July 31, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on December 16, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 coinsurance 
for durable medical equipment (DME) provided on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased on 
February 3, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from by an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that coverage is provided for 
hearing aids purchased through the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261 x 2) purchased on February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 43248 and 99152 provided on July 20, 
2022. 
 
You asked the Plan to pay for procedure codes 43248 and 99152. You say that the medical records support the 
billing of codes 43248 and 99152. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 43248 and 99152. 
 
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 43248 is Esophagogastroduodenoscopy, flexible, 
transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire. 
The definition of code 99152 is Moderate sedation services provided by the same physician or other qualified 
health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring 
the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 
 
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 procedure code 43248. Our reviewer says that the medical 
records do not support the billing of code 43248. Our reviewer found the medical record does not include 
documentation that an esophagogastroduodenoscopy (EGD) procedure has been performed, and therefore 
cannot be verified.  Unable to cite report as this procedure was not found in medical record submitted for 
review. 
 
We also find that CPT code 99152 is not supported in the medical record. Specifically, the record does not 
document that moderate sedation services were provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 43248 and 99152 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 43248 and 99152 provided on July 20, 2022.
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 is at risk for a poor outcome, 
readmission, or even death if discharged to any lower level of care. The Plan denied your request. The Plan 
says the request is not medically necessary, when the enrollee is ready to leave the hospital, they can safely 
receive this care in another setting, such as a Skilled Nursing Facility (SNF). 
 
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 the medical records do not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH 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 pay for procedure codes 99222 and 99232 billed for dates of service 
from April 25, 2022, to April 26, 2022. 
 
You asked the Plan to pay for procedure codes 99222 and 99232. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says payment for code 99222 is bundled into payment 
for code 99223. The Plan also says that the claim for code 99232 is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that claims or claim lines that 
have been determined to be exact duplicates of another claim or claim line are denied. However, such denials 
may be appealed.  
 
In this case, we have confirmed that code 99222 is a column II code to column I code 99223. 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. 
 
Additionally, the file includes evidence that the items/services denoted by code 99232 were reimbursed by the 
Plan on June 30, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed items/services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for procedure code 99232 have not been met.  
 
Therefore, we decided that the Plan does not have to pay for procedure codes 99222 and 99232 billed for dates 
of service from April 25, 2022, to April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not 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 treat with 
insulin three or more times per day or use an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitors (CGM) 
sensor (A4239). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM sensor. You say that the enrollee has type 2 
diabetes mellitus and is currently treated with insulin once per day. 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. Based on this information, we decided that Medicare rules for coverage of a 
Freestyle Libre 2 CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitors (CGM) sensor (A4239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is needed to prevent or 
decrease readmission and death from respiratory failure. The Plan denied your request. The Plan says under 
Medicare guidelines, your request is not medically necessary because your records show you that the ordered 
settings for the noninvasive ventilator can be delivered by a bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) capability. 
 
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 that this enrollee has a diagnosis of 
severe COPD, although there are no pulmonary function test results to confirm severity. The enrollee was 
hospitalized with an exacerbation in December 2022, and arterial blood gas (ABG) was consistent with acute 
on chronic hypercarbic respiratory failure. There is no documentation of chronic CO2 retention with an ABG 
done while stable. Medicare does not cover a home ventilator when used at settings that can be provided with 
BiPAP. Battery backup of the device is not medically necessary for 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on October 27, 
2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
 We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids purchased on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and lenses provided on December 1, 2022.  
You asked the Plan to pay for the frames and lenses. You say that you waited a year to get new glasses. 
 The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 these services once a year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for frames and lenses on December 11, 
2021, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of 
the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames and lenses provided on December 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 3, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 3, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial hospitalization. 
 
You asked the Plan to pre-approve partial hospitalization. You say that the requested partial hospitalization is 
medically necessary. The Plan denied your request. The Plan says the condition can be treated on an 
ambulatory basis with an increase of the number of visits with the psychiatrist and with revision or 
optimization of medications. 
 
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 partial hospitalization. Our reviewer 
says that the requested partial hospitalization is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that based upon review of the records provided, you were not showing any 
dangerousness to self or others with no intention or suicidal plan and is not exhibiting severe psychiatric impairment requiring this level of care. You were not showing any perceptual disturbance, psychosis or 
aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at 
the partial hospitalization level of care rather than a lower level of care as you did not have any suicidal or 
homicidal thoughts or behavioral disturbance and your symptomatology could be treated at a lower level of 
care. The health Plans denial of continued partial hospitalization treatment for the dates in question appears 
appropriate. You did not appear to require partial hospitalization treatment. You were not showing any severity 
of psychological or psychiatric illness. Based upon review the records provided, you do not meet the criteria for 
treatment at partial hospitalization level of care and could have been treated in a lesser restrictive setting as you 
were not showing any suicidal or homicidal ideation and was not showing any psychosis or aggressive 
behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial hospitalization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve partial hospitalization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on December 14, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you needed these services. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 4, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
December 14, 2022.