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

 
We decided that the Plan does not have to pay for inpatient services provided from June 25, 2021, through June 
28, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that the enrollee met the sepsis 2 criteria 
and there is clinical support throughout the medical records for this diagnosis. You say that you are disputing 
the removal of this diagnosis code that downgraded the DRG. The Plan denied your request. The Plan says the 
documentation does not support principal diagnosis code A40.3. 
 
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 with principal diagnosis code A40.3, defined as sepsis due to 
Streptococcus pneumoniae. 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 inpatient services 
at DRG 871. Our reviewer says that the documentation does not support principal diagnosis code A40.3. Our 
physician reviewer found the enrollee was described as being alert and oriented throughout the stay and no 
acute mental status changes were noted. The records do not show evidence of significant hypoxemia, 
thrombocytopenia, hypotension, presence of a significant acute mental status change or significant renal or 
hepatic dysfunction beyond the enrollee's baseline to suggest a dysregulated host response to an infection was 
present.  
 
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 services provided from June 25, 2021, through June 28, 2021, at DRG 871.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to provide reimbursement of the Medicare-allowed amount for the applicable 
covered bifocal code for the lenses. We decided that the Plan does not have to provide full reimbursement for 
the eyeglass lenses.  
 
You asked the Plan to provide reimbursement for the eyeglass lenses. You say that you were not aware that 
progressive lenses are not covered by Medicare. The Plan says that customer service records indicate that you 
were informed that progressive lenses are not covered by Medicare. Therefore, no reimbursement is allowed 
for this purchase. 
 
We decided that the Plan has to provide reimbursement up to the Medicare allowed amount for the 
applicable covered bifocal code for the lenses.  
 
The Plan must follow Medicare rules. The rules say that progressive lenses are not covered by Medicare. 
However, the rules also indicate that Medicare does make payment for the lenses as if they were standard 
bifocals, with the additional charge for upgrade to progressive lenses being the responsibility of the enrollee.  
 
These eyeglasses are noted to have been provided after cataract surgery, meaning they are eligible for Medicare 
coverage. As such, application of the Plans supplemental benefit limit of $100 is not appropriate. The Plan 
must at least reimburse the amount that would be paid if you had received non-progressive bifocal lenses. 
Therefore, we decided that the Plan has to provide reimbursement for the applicable covered bifocal code for 
the lenses.  
 
We also decided that the Plan does not have to provide full reimbursement for the eyeglass lenses. 
 
Medicare rules indicate that enrollees are responsible for the additional charge for upgrade to progressive 
lenses. 
 
You elected to purchase progressive lenses rather than standard bifocals. As such, any amount you paid in 
excess of the allowed amount of the standard bifocals remains your responsibility and cannot be reimbursed.  
Therefore, we decided that the Plan does not have to provide full reimbursement for the eyeglass lenses. 
 
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 pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested foot inserts are medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a health club membership (S9970) provided on February 14, 
2022. 
 
You asked the Plan to pay for a health club membership. You say that the gym at issue is for people with 
disabilities. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only obtained through participating providers. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the gym at issue is not a participating 
provider. Therefore, we decided that the Plan does not have to pay for a health club membership (S9970) 
provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external ear biopsy, office visit, and destruction of skin 
growths provided on February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the external ear biopsy, office visit, and destruction of skin growths. You say that 
you are appealing this claim. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
external ear biopsy, office visit, and destruction of skin growths. We found no exception that would require the 
Plan to pay for the external ear biopsy, office visit, and destruction of skin growths. The records provided for 
review do not show that the external ear biopsy, office visit, and destruction of skin growths were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the external ear biopsy, office visit, and 
destruction of skin growths provided on February 8, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply (K0553) provided December 5, 2021. 
 
You asked the Plan to pay for the CGM supply allowance. You say that as a supplier, you must monitor the 
usage of beneficiaries monthly supply allowance and ensure beneficiaries has enough supplies (sensors) on 
hand before billing the monthly supply allowance. The Plan denied your request. The Plan says the records do 
not support the service billed. 
 
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.  
 The record does not contain a valid proof of delivery, or a valid delivery ticket. It is noted that the proof of 
delivery is dated 12/06/2021 and there is no shipping invoice found. The provider listed the date of service as 
12/05/2021. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic 
continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply (K0553) provided 
December 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiological monitoring services provided on 
December 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the remote physiological monitoring services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
remote physiological monitoring services. We found no exception that would require the Plan to pay for the 
remote physiological monitoring services. The records provided for review do not show that the remote 
physiological monitoring services were urgent or emergent. Therefore, we decided that the Plan does not have 
to pay for the remote physiological monitoring services provided on December 31, 2021, by an out-of-network 
(OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that no one advised you that your coverage in 
the SNF was ending and that you would have to pay out of pocket. You cannot afford to cover the rates of the 
SNF, and you need to continue to stay there because you are still very weak and need therapy. The Plan denied 
your request. The Plan says you have exhausted your skilled nursing benefits. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 2, 2022, through 
March 14, 2022, and March 16, 2022, through July 10,2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for meningococcal vaccination (90620) provided on September 
29, 2021. 
 
You asked the Plan to pay for meningococcal vaccination. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for immunizations 
have not been met. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide meningococcal 
vaccination. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to meningococcal 
vaccination. Therefore, we decided that the Plan does not have to pay for meningococcal vaccination (90620) 
provided on September 29, 2021.  
 Benefits for meningococcal vaccination may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the LipiFlow procedure provided on February 10, 2022. 
 
You asked the Plan to pay for the LipiFlow procedure. You say that the LipiFlow procedure was medically 
necessary. The Plan denied your request. The Plan says the LipiFlow procedure was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the LipiFlow procedure. Our reviewer says 
that the LipiFlow procedure was not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has dry eyes.  There is insufficient literature to support the use of the requested service for the 
enrollee's condition. The records provided are insufficient to determine the medical necessity of the requested 
procedure for the enrollee's specific clinical situation. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied.  The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LipiFlow procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the LipiFlow procedure provided on February 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are diabetic, and 
you have dialysis appointments 3 days per week. You are unable to pay for additional trips and have been 
missing your treatments. The Plan denied your request. The Plan says you have exhausted the maximum 
benefit of 60 one-way trips per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for occupational therapy. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says there are in-network providers available for these 
services. 
 
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 occupational therapy provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM) 
receiver/monitor (K0554). 
 
You asked the Plan to pre-approve the therapeutic CGM receiver/monitor. You say that you are appealing the 
denial of the continuous glucose monitor. The Plan denied your request. The Plan says the enrollee uses insulin 
once a day and does not meet the criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the therapeutic CGM receiver/monitor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose 
monitor (CGM) receiver/monitor (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that a wheelchair is your only way of moving 
around the house and that your current wheelchair is falling apart. The Plan denied your request. The Plan says 
that your records do not show that your wheelchair has been lost or damaged due to an accident or natural 
disaster. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no 
case can be less than five years. You received a power wheelchair in 2021, which is less than five years ago. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the laboratory services 
rendered on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you cannot walk a far distance and only 
walk in the home with use of a cane. The Plan denied your request. The Plan says that the notes provided show 
you are able to move around and complete daily activities with a manual wheelchair, walker or cane. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic pillow. 
 
You asked the Plan to pre-approve an orthopedic pillow. You say that you require this pillow to sleep well. The 
Plan denied your request. The Plan says that this is not covered by Medicare. 
 
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 an orthopedic pillow.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic diabetic shoes (A5500) 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting approval of the therapeutic 
shoes for the treatment of severe neuropathy in your toes, feet and ankles. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the therapeutic diabetic shoes 
(A5500)