Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee is weak and needs rehabilitation.  
The Plan denied your request. The Plan says daily skilled nursing and therapy is not medically necessary. 
 
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 pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and her 
lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the 
enrollee was at a contact guard to minimal assist level with functional mobility. She required varying assist 
with activities of daily living. Although there are identifiable skilled therapy service needs, she does not require 
skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs cannot be 
accomplished at a lower level of care. The Plan denied your request. The Plan says there is no documentation 
that the enrollee will benefit from and improve with LTACH management. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital and treated for a myocardial infarction, 
pulseless electrical activity, heart failure, acute respiratory failure, acute renal failure, pneumonia, anemia, and 
delirium. He required mechanical ventilation support. He appears to be stable and improving and should only 
require short-term additional acute care services that can be safely completed at the current location. The 
enrollee does not require services at the LTACH that are not already available at the current facility.  Transfer 
to LTACH is not medically necessary as it would not be clinically advantageous at this time. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553). 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed item. 
 
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 proof of delivery. The record does not show the specific supplies delivered. 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 a continuous glucose monitor (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services (99441) provided on October 21, 
2021. 
 
You asked the Plan to pay for code 99441. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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  is Telephone evaluation and management service by a 
physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion. 
 
We find that CPT code  is not supported in the medical record. Specifically, it is not appropriate to report this procedure separately. An evaluation and management (E/M) service was billed three days prior. Based on this 
information, we decided that Medicare rules for coverage of code 99441 have not been met. Therefore, we 
decided that the Plan does not have to pay for the telehealth services (99441) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided September 9, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is inclusive to another code billed and not separately 
payable.  
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 99239 
is a column II code to column I code 31500. 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 physician services (99239) provided September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve therapeutic CGM. You say that you need this so you can monitor your 
blood sugar more regularly. The Plan denied your request. The Plan says you do not meet the Medicare 
coverage criteria for a therapeutic 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 you do 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 your 
treating physician to assesses adherence to CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and manipulation of the spine 
(98940) provided on December 8, 2021. 
 
You asked the Plan to pay for the office visit and manipulation of the spine. You say that you would like 
reconsideration because you were given incorrect information by the Plan. The Plan denied your request. The 
Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The office visit provided is not considered manual manipulation of the spine. Additionally, CPT code 98940 
for manual manipulation of the spine was not billed with the required AT modifier. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and manipulation of the spine (98940) provided on 
December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek test strips (360 per 75 days). 
 
You asked the Plan to pre-approve Accu-Chek test strips (360 per 75 days). You say that the requested Accu-
Chek brand diabetic supplies are more medically appropriate over the Plan's preferred brands, and the 
requested higher amount of more than 300 test strips every 3 months is medically necessary. The Plan denied 
your request. The Plan says that neither the requested Accu-Chek brand diabetic supplies are more medically 
appropriate over the Plan's preferred brands, nor the requested higher amount of more than 300 test strips every 
3 months is 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 Accu-Chek test strips (360 per 75 
days). Our reviewer says that neither the requested Accu-Chek brand diabetic supplies are more medically 
appropriate over the Plan's preferred brands, nor that the requested higher amount of more than 300 test strips 
every 3 months is medically necessary. Our physician reviewer found records do not document necessity of the 
Accu-Chek brand test strips over the plan preferred Abbott and Lifescan glucometers and Abbott products. 
Based on the medical records provided 360 Accu-Chek Guide test strips for 75 days have been requested. This 
averages to 4.8 tests strips per day. Provided records document that the enrollee tests 3-4 times daily. Records 
do not document necessity of the quantity of requested test strips as required by the LCD. The LCD states: 
"Within the six (6) months prior to ordering quantities of strips and lancets that exceed the utilization 
guidelines, the treating practitioner has had an in-person visit with the beneficiary to evaluate their diabetes 
control and their need for the specific quantity of supplies that exceeds the usual utilization amounts described 
above." These criteria are not met with the provided records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Accu-Chek test strips (360 per 75 days) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Accu-Chek test strips (360 per 75 days).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81301, 81311, and 81321) provided on October 26, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, and 
81321) provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Accu-Chek Guide Monitor. 
 
You asked the Plan to pre-approve an Accu-Chek Guide Monitor. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says Accu-Chek is not a preferred brand. 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. The requested Accu-Chek Guide Monitor is produced by Roche. 
Only diabetic test supplies by Abbott or LifeScan are covered. Therefore, we decided that the Plan does not 
have to pre-approve an Accu-Chek Guide Monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99220) provided June 16, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records provided do not support the billed services. 
 
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 physician services (99220) provided June 16, 2021. have been met. Insufficient medical records were provided to support the billed services. 
Therefore, we decided that the Plan does not have to pay for physician services (99220) provided June 16, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed an oral bisphosphonate drug and 
zoledronic acid. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post-anesthesia care unit (PACU) nurse services 
represented by code 99199 provided on October 27, 2021. 
 
You asked the Plan to pay for code 99199. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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 code 99199 is Unlisted special service, procedure or report. 
 
We find that CPT code 99199 is not supported in the medical record. Specifically, in this case, code 99199 
represents post-anesthesia care unit (PACU) nurse services. Per Medicare guidelines, an anesthesia care 
package consists of preoperative evaluation, standard preparation and monitoring services, administration of 
anesthesia, and post-anesthesia recovery care. Therefore, this procedure should not be separately reported. Therefore, we decided that the Plan does not have to pay for the post-anesthesia care unit (PACU) nurse 
services represented by code 99199 provided on October 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (27096) provided March 25, 2021 
 
You asked the Plan to pay for the injection. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 27096 is not supported in the medical record. Specifically, the code billed did not 
include a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage 
of the injection have not been met. Therefore, we decided that the Plan does not have to pay for an injection 
(27096) provided March 25, 2021
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Biofeedback therapy. 
 
You asked the Plan to pre-approve the Biofeedback therapy. You say that you would like reconsideration 
because you are having issues with your bladder and stool. The Plan denied your request. The Plan says the 
notes do not show that you have muscle abnormalities of spasticity, muscle spasm that gets in the way of 
your normal function, or weakness. 
 
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 Biofeedback therapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it was not clear that you do not understand how to perform simple exercises for the 
pelvic floor. The records did not show documentation of completed pelvic floor therapy to cooroborate your 
report of this having been completed already. Based on the documenation, it appears that the reason the 
physician recommended biofeedback was to help you with psychological factors such as anxiety. 
 
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 Biofeedback therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Biofeedback therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 84100) provided 
July 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were 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 all laboratory services furnished to individuals 
for the treatment of End-Stage Renal Disease (ESRD) are included in the ESRD PPS as Part B services and are 
not paid separately as of January 1, 2011. 
 
We looked at the file and Medicare rules. The services are related to ESRD treatment and are included in 
payment to the ESRD facility. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(82310, 82728, 83540, 83550, 84100) provided July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
November 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are being charged for services that have a 
$0 copayment. The Plan denied your request. The Plan says that the benefit maximum has been exhausted. 
 
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. Specifically, there was no documentation provided to substantiate the Plan's 
claim that the $1,000 maximum benefit had been exhausted. We requested this information, and nothing was 
received. Without this documentation we cannot determine that the maximum benefit had been exhausted. 
Therefore, we decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
November 29, 2021.  
 
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.