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

 
We decided that the Plan does not have to pay for hospital care (procedure code 99223, 99497) rendered on 
May 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
CPT 99497: 
 
Advance care planning including the explanation and discussion of advance directives such as standard forms 
(with completion of such forms, when performed), by the physician or other qualified health care professional; 
first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the CPT code 99223.  The documentation does not indicate the encounter required medical 
decision making of high complexity. Additionally, the documentation does not support that 30 minutes was 
spent on advance care planning. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital care (procedure code 99223, 99497) rendered on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary 
because the hospital will not release you without it. The Plan denied your request. The Plan says a ventilator is 
not medically necessary as a BiPAP with AVAPS would meet your needs. 
 
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 necessary. Our physician reviewer found you have chronic obstructive 
pulmonary disease (COPD) and are on a standard auto bilevel positive airway pressure (BiPAP) at home. It 
appears you have utilized the BiPAP for 7 days. The submitted pulmonary evaluation is limited to arterial 
blood gas showing hypercarbia. The provider did not submit any additional pulmonary information including 
baseline arterial blood gas analysis (ABG), complete pulmonary function testing (PFT), polysomnography 
(PSG), or oximetry. You were recently admitted to acute care for atrial fibrillation (afib) and COPD and 
improved with appropriate therapies. 
 
You do not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent 
to chronic obstructive pulmonary disease. The documentation in the medical record does not support that the 
ventilator at issue is medically necessary and reasonable for you. Your providers did not submit a compelling 
rationale that supports use of a home mechanical ventilator (HMV) to deliver this assistance rather than a 
BiPAP with a backup rate and AVAPS. 
 
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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
  You asked the Plan to pre-approve additional mileage. You say that you are getting treated for periodontal 
disease, will be sedated, and need to be monitored during the procedure. You also say that you are going to the 
closest in-network provider. The Plan denied your request. The Plan says you are requesting an additional eight 
miles for a total of 58 miles. The Plan also says that your benefit only allows 50 miles, and you have exceeded 
your benefit limit. 
 
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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the record shows 
you are requesting to be transported more than 50 miles one way. Therefore, we decided that the Plan does not 
have to pre-approve additional mileage.
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 sensors. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) and sensors. You 
say that your doctor said that you need to monitor you blood sugar, as it lowers and then spikes. You also say 
that you are in pain having to prick your fingers. The Plan denied your request. The Plan says the clinical 
information provided indicates that you take Soliqua daily and does not indicate that you take three or more 
daily insulin injections. 
 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 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 2 
continuous glucose monitor (CGM) and sensors 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 sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on August 5, 2021. 
 
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your 
request. The Plan says this claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until October 5, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is not safe for you to go home by yourself as you 
are at risk for falling. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic consult to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the orthopedic consult. You say that the service should be covered. The Plan 
denied your request. The Plan says there are in-network provider(s) within a reasonable distance from the 
members location that can provide this service. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the orthopedic consult to be 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 a Freestyle Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee needs this CGM. The Plan denied your 
request. The Plan says the medical criteria for a CGM have 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 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 CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous 
glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the iStent infinite device (0671T). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary and does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The requested device is not considered medically reasonable or necessary by Medicare at this time. Based on 
this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the iStent infinite device (0671T).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 9, 
2020, to November 7, 2020. 
 You asked the Plan to pay for SNF care. You say that these services should be paid. The Plan denied your 
request. The Plan says the enrollee no longer had skilled nursing facility needs on the dates of service at issue. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from October 9, 2020, to November 7, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
October 30, 2022, to November 30, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for emergency room services. This item/service falls within the 
emergency 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 waive the copayment for emergency room services 
provided on October 30, 2022, to November 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
12, 2022 to December 11, 2022. 
 You asked the Plan to pay for SNF care. You say that these services should be paid. The Plan denied your 
request. The Plan says the enrollee no longer had skilled nursing facility needs on the dates of service at issue. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from November 12, 2022 to December 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24-hour private duty nursing. 
 
You asked the Plan to pre-approve private duty nursing. You say that you want private duty nursing because 
you had a knee replacement last year where you had to go to a skilled nursing facility, and it was not a good 
experience. You said that you have no family to help you when you leave the hospital. The Plan denied your 
request. The Plan says private duty nursing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a private duty nurse or other 
private-duty attendant are not covered by Medicare. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of private duty nursing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 24-hour private duty nursing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 9, 2022, 
through January 12, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were in the hospital from having back 
surgery and were unaware of what drugs were given to you. The Plan denied your request. The Plan says self-
administered drugs do not fall under Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from January 9, 2022, through January 12, 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 the enrollee does have a qualifying diagnosis, 
and is at high risk for an unplanned hospitalization within the next 60 days. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular screening/risk assessment panel (81225, 
81226, 81227, 81231, 81240, 81241, 81291, 81306, 81328, 81335, 81479, 81238) provided on August 4, 2022. 
 
You asked the Plan to pay for the cardiovascular screening/risk assessment panel. You say that this claim 
should be covered. The Plan denied your request. The Plan says screening tests are not covered. Additionally, 
the Plan says that panel should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and Medicare rules. Medicare does not cover this test solely for screening purposes. 
Based on this information, we decided that Medicare rules for coverage of the cardiovascular screening/risk 
assessment panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular screening/risk assessment panel (81225, 81226, 81227, 81231, 81240, 81241, 81291, 81306, 
81328, 81335, 81479, 81238) provided on August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) 
supplies and accessories. 
 
You asked the Plan to pre-approve the CPAP supplies and accessories. You say that the items should be 
covered. The Plan denied your request. The Plan says there is no record a CPAP and supplies were 
ordered/approved or delivered and no medical records to indicate medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the CPAP supplies and accessories 
have been met. There are no medical records or records of any CPAP authorization, claim, or approvals of any 
kind for a CPAP machine.  Therefore, we decided that the Plan does not have to pre-approve the continuous 
positive airway pressure (CPAP) supplies and accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 20, 2022. 
 You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on May 20, 2022.