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

 
We decided that the Plan does not have to pay for the office visit and destruction of premalignant lesion 
provided on February 1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the enrollee has been seen in this practice 
since 2019 on a yearly basis for skin cancer screening. You also say that the provider's office was not aware of 
the change in the enrollee's insurance until they arrived for the appointment. The Plan denied your request. The 
Plan says prior authorization was not obtained. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 and destruction of premalignant 
lesion provided on February 1, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on November 25, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you are not seeking payment for the 
requested item and would like to change the type of denial. The Plan denied your request. The Plan says the 
requested item is a non-covered item by the Plan or Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on November 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided by a medical 
student on September 29, 2022. 
 
You asked the Plan to pay for the ER services provided by a medical student. You say that the service should 
be covered. The Plan denied your request. The Plan says Medicare does not pay for any service furnished by a 
student. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for any service furnished 
by a student. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ER services provided by a medical student have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided by a medical student on September 
29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on November 15, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the eye exam. You say that you believe it is imperative that the Plan reimburse 
the treating provider for all services rendered, to avoid making a patient unfairly responsible for the unpaid 
balance. The Plan denied your request. The Plan says the treating provider is a non-network provider who does 
not work with the enrollees health plan and the enrollee was referred by a non-participating outpatient nursing 
facility. The Plan also says the enrollee's primary care physician (PCP) did not refer for services, and no 
medical necessity for an OON provider, such as an urgent or emergency situation, has been documented 
 
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 eye exam (92014) provided on November 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for free muscle or myocutaneous flap with microvascular anastomosis 
(15756) provided on May 5, 2022. 
 
You asked the Plan to pay for free muscle or myocutaneous flap with microvascular anastomosis. You say that 
you want the Plan to pay for this service. The Plan denied your request. The Plan says that service is not 
supported without documentation. 
 
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 asked our physician 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 free muscle or myocutaneous flap with microvascular 
anastomosis. Our reviewer says that the record showed that the services described by code 15756 were 
performed (free muscle or myocutaneous flap with microvascular anastomosis) and this service was medically 
reasonable and necessary. 
 
We looked at this physicians's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of free muscle or myocutaneous flap with microvascular anastomosis have been 
met. Therefore, we decided that the Plan has to pay for free muscle or myocutaneous flap with microvascular 
anastomosis (15756) provided on May 5, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of an IRF admission. The Plan denied your request. The Plan says the request for admission to an IRF is not 
medically necessary.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 12, 2022, to July 
15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as Sepsis, 
unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found that the enrollee is a 72-year-old female who was presented with fever and chills 
following recent diagnosis and treatment for urinary tract infection. Vitals showed low grade fever but 
otherwise stable. Workup revealed leukocytosis and positive urinalysis and she was started on antibiotics. 
Other workup revealed normal creatinine, normal platelet count, normal bilirubin, no oliguria, stable blood 
pressure and oxygenation throughout monitoring, and the patient was alert and oriented with a Glasgow coma 
score of 15. Based on the above findings, this enrollee does not meet Sepsis 3 criteria and did not exhibit signs 
of a dysregulated response leading to life-threatening organ failure. Therefore, the code, A41.9 is not supported 
for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 12, 2022, to July 15, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 21, 2022, to 
November 18, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 21, 2022. The NOA was not received by the Plan until December 
22, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 21, 2022, to November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the facet joint 
injections 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 the injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has a long 
history of low back pain and has had physical therapy in the past. The enrollee underwent medical branch 
blocks (MBB) of L3, L4 and L5 with 50% pain relief for 5 hours and then 20% pain relief for 2 more hours. 
However, the LCD criteria mandates 80% pain relief to be considered a positive block. Therefore, the request 
is not medically 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 28, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that the claim was submitted to insurance in a 
timely manner. The Plan denied your request. The Plan says the claim was not filed timely. 
 
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 service was not filed until February 23, 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 office visit provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 12, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that the claim was initially paid under another 
plan. You say that payment was retracted due to the enrollee having a primary plan. You say that the 
coordination of benefits (COB) was not updated until June 28, 2022, and payment retraction was not made until 
November 4, 2022. You also say that this should be reprocessed for payment. The Plan denied your request. 
The Plan says the claim was not filed timely. 
 
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 service was not filed until October 4, 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 provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from December 2, 2022, to December 
7, 2022. 
 
You asked the Plan to pay for the 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 1, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided 
from December 2, 2022, to December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) device provided on 
April 30, 2022. 
 
You asked the Plan to pay for a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says a CGM is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a CGM. Our reviewer says that the medical 
criteria for a CGM have not been met. Our physician reviewer found the supplied medical records do not 
document use of sliding scale insulin or show that the patient's insulin treatment regimen requires frequent 
adjustment by the patient on the basis of glucose monitor testing results. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM) device provided on April 30, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from January 15, 2022, to March 15, 
2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says that the NOA was not received timely. As such, this final claim 
was correctly denied. 
 
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, the start of care date is January 15, 2022. The Plan's denial 
indicates that the NOA was not received by the Plan until April 4, 2022. However, the case record does not 
include the untimely NOA. We are unable to verify that the NOA was submitted untimely. It is the Plan's 
responsibility to support its denial with evidence. In this case, the Plan's denial has not been supported, so we 
must find in your favor. Therefore, we decided that the Plan has to pay for home health services provided from 
January 15, 2022, to March 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that the item should be covered. The Plan 
denied your request. The Plan says this item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 20, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are separately billable. 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 the wound care supplies 
provided on January 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on December 6, 
2022, to December 9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis codes were appropriate. The Plan denied your request. The Plan says the documentation did not 
clinically validate the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code J96.01, defined as acute respiratory failure 
with hypoxia, and diagnosis code N17.9, defined as acute kidney failure. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our physician 
reviewer found that the enrollee presented to the hospital with fever and cough. Imaging revealed pneumonia 
and the enrollee was started on antibiotics, fluids, and low dose oxygen support. The workup revealed a low-
grade fever. The enrollee was awake and alert, lying comfortably without respiratory distress. There was no 
record of the enrollee requiring high flow oxygen support, bi-level positive airway pressure, or vent support to 
justify the acute respiratory failure with hypoxia code (J96.01). Also, the enrollees creatine (Cr) was 1.5 with 
repeat readings 1.3 and 1.1 over the course of 2 days of treatment. There was no reported oliguria. There was 
no increase of the Cr of 1.5 times their baseline or a rise over 48 hours to meet criteria for acute kidney failure. 
The enrollee was improving with fluids. Therefore, the acute kidney failure code, N17.9 is also not supported 
in the documentation for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on December 6, 2022, to December 9, 2022, at the Diagnosis 
Related Group (DRG) originally billed.