Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion 
catheter, per week (list drugs separately) (A4221) and infusion supplies not used with a covered external 
infusion pump (A4223) provided April 7, 2023, to April 13, 2023. 
 
You asked the Plan to pay for the infusion supplies. You say that you provided intravenous (IV) infusion 
therapy for the enrollee at home and the IV Home infusion supplies were omitted from the reimbursement. The 
Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no documentation that the supplies are used with a covered 
external infusion pump. Disposable drug delivery systems, including elastomeric infusion pumps are non-
covered devices because they do not meet the Medicare definition of durable medical equipment. Drugs and 
supplies used with disposable drug delivery systems are also non-covered items. Based on this information, we 
decided that Medicare rules for coverage of the infusion supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion catheter, per week 
(list drugs separately) (A4221) and infusion supplies not used with a covered external infusion pump (A4223) 
provided April 7, 2023, to April 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that rehabilitation is needed to recover from your 
treatment. The Plan denied your request. The Plan says the denial of SNF care is correct. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission following an elective 
foot and ankle surgery. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the patient needs the inpatient 
stay due to having fusions of their mid foot, and will be non-weight bearing for 12 weeks. You also say that the 
patient is alone and will need at least three days to recover. The Plan denied your request. The Plan says there 
is no documentation provided to support the expectation the patient will require a greater than 2 midnight stay. 
 
 
 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this 
case. Our physician reviewer found the record does not show that the physician expects that the patient's 
necessary hospital care will span two midnights with supporting documentation of the patients history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission following an elective foot and ankle 
surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient telehealth office visit (99213) provided on 
June 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the telehealth visit. You say that the medical service in question was deemed 
medically necessary by the attending physician. The Plan denied your request. The Plan says if you choose to 
get one of these services by telehealth, you must use a network provider who offers the service by telehealth. 
 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 the outpatient telehealth office visit (99213) 
provided on June 20, 2023, 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 group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. The Plan denied your request. 
The Plan says the power scooter requested does not meet the requirements for approval. 
 
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.  
 
 
 
 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 group 1 standard power operated 
vehicle. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer 
found the enrollee has a frozen shoulder and painful knee. They have no neurologic deficits and are 
ambulatory. Our reviewer also found that the enrollee does not require a mobility device to complete 
MRADLs. 
 
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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of SNF care is correct. 
 
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 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 27, 
2023. 
 
You asked the Plan to pay for procedure code 88341. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the code at issue is an add-on code without an 
appropriate primary procedure.  
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 
procedure code 88341 is an add-on code and has not been billed with an appropriate primary procedure code. 
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 88341 billed for date of service February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 28, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was medically necessary. 
 
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 the office visit provided on June 28, 2023, by an 
OON provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service March 12, 2021, to 
April 2, 2021. 
 
You asked the Plan to pay for the billed services. You say that there was no overlap in services. The Plan 
denied your request. The Plan says that preadmission services are included within the inpatient reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The period of care in this case is from March 12, 2021, to April 2,2021. The 
enrollee does not have to be discharged within the period because of admissions to other types of health care 
providers. The first visit within the period of care was on March 15, 2021, after the enrollee was discharged 
from inpatient services. Based on this information, we decided that Medicare rules for coverage of the billed 
services have been met. Therefore, we decided that the Plan has to pay for the home health care billed for dates 
of service March 12, 2021, to April 2, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable auto continuous positive airway pressure 
(CPAP) machine. 
 
You asked the Plan to pre-approve a portable CPAP machine. You say that the enrollee is a frequent travel and 
would benefit from a portable CPAP machine for travel use. The Plan denied your request. The Plan says the 
medically necessary criteria has not been met.  
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a continuous positive airway pressure machine which was provided on March 1, 
2022. The continuous positive airway pressure machine serves the same purpose as a portable CPAP machine. 
The records provided does not show that you are using the current machine and the does not show that the 
frequent travel is for medically necessary purposes. Therefore, we decided that the Plan does not have to pre-
approve a portable auto continuous positive airway pressure (CPAP) machine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for chelation treatments provided from  
March 25, 2023, to April 18, 2023.  
 
You asked the Plan to reimburse you for chelation treatments. The Plan denied your request. The Plan says the 
services are not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of chelation treatments have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for chelation treatments provided from March 25, 2023, to April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital stay from September 26, 2022, through 
November 9, 2022. 
 
You asked the Plan to pay for the inpatient stay. You say that the inpatient stay should be paid because it took 
place at a Long-Term Acute Care Hospital, so Inpatient Rehabilitation Facility billing rules do not apply. The 
Plan denied your request. The Plan says that an inpatient rehabilitation room and board code was billed without 
an appropriate revenue code in accordance with Medicare rules for billing from Inpatient Rehabilitation 
Facilities. 
 
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. We confirmed that the inpatient stay in this case took place in a Long-Term 
Acute Care Hospital (LTACH) and not an Inpatient Rehabilitation Facility (IRF). We confirmed that the room 
and board services for this inpatient stay were billed with revenue code 0118. The Plan did not provide a 
Medicare rule which prohibits a LTACH from billing its room and board services under revenue code 0118. 
Also, the Plan did not provide a citation showing that billing revenue code 0118 for room and board services 
would indicate these services are IRF services. As a result, the IRF billing rules would not apply in this case. 
Therefore, we decided that the Plan has to pay for the inpatient hospital stay from September 26, 2022, through 
November 9, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87491, 87500, 87563, 87640, 87641, 
87653, 87798) provided on June 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that these 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798 are not supported in the 
medical record. Specifically, multiple unbundled codes were submitted for a single panel. 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 (87481, 87491, 87500, 87563, 87640, 87641, 87653, 
87798) provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shank foot system with vertical loading pylon, an axial 
rotation unit, and a BOA/Revo Click system.  
 
You asked the Plan to pre-approve a shank foot system with vertical loading pylon, an axial rotation unit, and a 
BOA/Revo Click system. You say that the requested shank foot system with vertical loading pylon, an axial rotation unit, and a BOA/Revo Click system are medically necessary.  The Plan denied your request. The Plan 
says the requested shank foot system with vertical loading pylon, an axial rotation unit, and a BOA/Revo Click 
system are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a shank foot system with vertical 
loading pylon, an axial rotation unit, and a BOA/Revo Click system. Our reviewer says that the requested 
shank foot system with vertical loading pylon, an axial rotation unit, and a BOA/Revo Click system are not 
medically necessary.  Our physician reviewer found a new lower extremity prosthesis has been approved for 
the enrollee. Provided medical records from the enrollee's treating medical provider do not document medical 
necessity of the shank foot system with vertical loading pylon, the axial rotation unit, and the BOA/Revo Click 
system. 
 
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 shank foot system with vertical loading pylon, an axial rotation unit, and a 
BOA/Revo Click system have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a shank foot system with vertical loading pylon, an axial rotation unit, and a BOA/Revo Click system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services with an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve the OON psychotherapy services. You say that you've been seeing this 
provider for a long time, and she already knows your issues. The Plan denied your request. The Plan says the 
provider being requested is not Medicare approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services with an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided 
October 3, 2022. 
 
You asked the Plan to pay for the orthosis. You say that kindly find the attached documents and process the 
claim for payment. The Plan denied your request. The Plan says the enrollee was inpatient at the time the 
orthotic was provided. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the orthosis was used in a SNF or hospital. Therefore, we decided that the Plan does not 
have to pay for the thoracic-lumbar-sacral orthosis (L0457) provided October 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiological services provided on June 7, 2023, billed with procedure 
code 74177-26. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the service exceeded what was approved on 
the authorization. 
 
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. We reviewed the Plans denial rationale for this code, and we find that the 
rationale is not valid. These services were provided by an interpreting radiologist who would not have the 
opportunity to obtain authorization. As no other valid rationale was provided, we find that the denial of 
payment is not substantiated. Therefore, we decided that the Plan has to pay for the services described by code 
74177-26. Therefore, we decided that the Plan has to pay for radiological services provided on June 7, 2023, 
billed with procedure code 74177-26.  
 
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.