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

 
We decided that the Plan has to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that without more advanced ventilatory 
support at home the enrollee would be at a high risk for death and hospital readmissions. The Plan denied your 
request. The Plan says that a home ventilator is not medically necessary for this patient because their needs can 
be met with an alternative device such as a BiPAP device with average volume-assured pressure support 
(AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 system. Our reviewer 
says that a home ventilator system is medically necessary. Our physician reviewer found that the enrollee has 
been on a home ventilator since December of 2021 and has been compliant with a good response. Therefore, to 
change the enrollee's ventilatory delivery at this time would be substandard medical care and not in the best 
interest of the enrollee or benefit. 
 
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 system have been met. Therefore, we decided that the Plan 
has to pre-approve a home ventilator system.  
 
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 procedure code 85025 provided on March 27, 2023. 
 
You asked the Plan to pay for procedure code 85025. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
85025. 
 
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 85025 is Blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the laboratory report 
provided does not include results for complete blood count (Hgb, Hct, RBC, WBC and platelet count) and automated differential white blood cell count. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85025 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 85025 provided on March 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on July 18, 2023. 
 
You asked the Plan to pay for psychotherapy services (90837). You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy services 
(90837) provided on July 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner visits (99306 and 99309) provided from January 
3, 2023, to May 2, 2023. 
 
You asked the Plan to pay for 99306 and 99309. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the records do not include the time component of these visits to 
support the codes 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 99306 is initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using total time on the date of the encounter for code 
selection, 45 minutes must be met or exceeded. The CPT Code Manual definition of code 99309 is subsequent 
nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time 
on the date of the encounter for code selection, 30 minutes must be met or exceeded. 
 
We find that CPT codes 99306 and 99309 are not supported in the medical record. Specifically, the records 
submitted do not include documentation of the time component of these services to support the specific codes 
billed on these claims. Based on this information, we decided that Medicare rules for coverage of 99306 and 
99309 have not been met. Therefore, we decided that the Plan does not have to pay for practitioner visits 
(99306 and 99309) provided from January 3, 2023, to May 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is necessary. The 
Plan denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's hospitalization has been complicated by atrial fibrillation and 
ventricular fibrillation cardiac arrest. The enrollee's needs are met in his current setting and do not meet the 
criteria for LTACH admission. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 21, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee was in a nursing home 
setting at the time services were rendered. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 03, 2023. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
August 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that a standard bi-level unit does not 
have the capability to provide the auto exhale that the physician ordered. The Plan denied your request. The 
Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that although the 
enrollee has COPD, the documentation does not support the need or requirement for a home ventilator. Also, 
there is no documented failure of a BiPAP or trial of a BiPAP with 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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 15, 2023. 
 
You asked the Plan to pay for OIVIT 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. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision item, the progressive lens, and the anti-reflective 
coating provided on June 27, 2023. 
 
You asked the Plan to pay for the vision items. You say that you should receive more of a reimbursement for 
the services. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers standard frames and lenses. 
 
We looked at the file and the Plan's rules. Specifically, the services are considered upgrades which are not 
covered benefits. Based on this information, we decided that the Plan's rules for coverage of the vision items 
have not been met. Therefore, we decided that the Plan does not have to pay for the vision item, the progressive 
lens, and the anti-reflective coating provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on May 31, 
2023. 
 
You asked the Plan to pay for remote patient monitoring services. You say that the provider must see all 
patients in the office that need care. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote patient 
monitoring services provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the lens (V2782) and anti-reflective coating (V2750) 
provided on August 1, 2022. 
 
You asked the Plan to pay more for the lens and anti-reflective coating. You say that you were charged $134.00 
and paid in full at the time. You also say that about 10 months later, you received a bill for $32.80, but you do 
not know where the $32.80 came from. The Plan denied your request. The Plan says the current claims 
processed correctly according to your benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a total of $200 every calendar year for eyeglasses, frames, lenses or contact 
lenses from participating network providers. 
 We looked at the file and the Plan's rules. Specifically, the record shows that the total charges for the lens 
(V2782), anti-reflective coating (V2750), and spherocylinder (V2107) was $299.00. The record shows that the 
Plan applied the full $200 allowance toward this purchase, and you are responsible for the remaining balance of 
$99.00 for the lens and anti-reflective coating. Based on this information, we decided that the Plan's rules for 
coverage of the lens and anti-reflective coating have not been met. Therefore, we decided that the Plan does not 
have to pay more for the lens (V2782) and anti-reflective coating (V2750) provided on August 1, 2022.  
 
Note: The provider confirmed the bill for $32.80 is for the anti-reflective coating. You may contact the 
provider if you have additional concerns regarding your balance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve SI RFA. You say that you are in pain and shots are not working. The Plan 
denied your request. The Plan says this procedure 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 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 SI RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental therapy because of the wide variation in efficacy reported in the 
literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the lens, the contact lens, the anti-reflective coating, the 
contact lens fitting, the diagnostic eye exam, and the diagnostic eye procedure provided on June 6, 2023. 
 
You asked the Plan to pay more for the vision services. You say that you had to pay out $600 because your 
insurance did not cover your eye service. You say you were told that the service was covered. The Plan denied 
your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $200 benefit maximum that applies to upgrades to post cataract 
surgery eyewear. 
 
We looked at the file and the Plan's rules. Specifically, the plan paid over $200 towards the services, which 
exhausted the benefit. Therefore, we decided that the Plan does not have to pay more for the lens, the contact 
lens, the anti-reflective coating, the contact lens fitting, the diagnostic eye exam, and the diagnostic eye 
procedure provided on June 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport services provided on March 22, 
2022. 
 
You asked the Plan to pay for the ambulance transport services. You say that the plan initially processed claim 
number ending in 440703 with the wrong date of service, May 17, 2023. You also say that you are asking that 
the claim be processed with the correct date of service and that you be reimbursed. The Plan denied your 
request. The Plan says the claim was not submitted within the 12 months of the date you received the service. 
 
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 ambulance transport services was not filed until July 24, 2023. 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 ambulance transport services provided on 
March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on April 14, 
2022. 
 
You asked the Plan to pay for the outpatient office visit. You say that you mailed these at least 3 times and 
faxed several times. The Plan denied your request. The Plan says this claim was untimely, and the submission 
did not meet the exception criteria guidelines. 
 
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 outpatient office visit was not filed until July 14, 2023. 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 outpatient office visit (99215) provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (RFA) (64625).  
 
You asked the Plan to pre-approve sacroiliac joint RFA. You say that you are in pain and have a hard time 
walking and sitting. You say you want to perform daily activities. The Plan denied your request. The Plan says 
the request is 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 sacroiliac joint RFA. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental/investigational due to the wide variation in efficacy reported in 
the peer reviewed literature. Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint radiofrequency ablation (RFA) (64625).