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

 
We decided that the Plan does not have to pre-approve continued continuous positive airway pressure (CPAP) 
therapy. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that continued CPAP use is covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has obstructive sleep apnea 
(OSA) and was prescribed CPAP therapy after a sleep study in 2021. The records do not include any 
subsequent clinical visits. Compliance device downloads covering October of 2022 to June of 2023 show she is 
using the device for at least four hours per day for less than 25 percent of the days. This does not meet the 
minimum requirement criteria; therefore, continued CPAP is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued continuous positive airway pressure (CPAP) therapy.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department (ED) consultation provided on March 2, 
2023.  
 
You asked the Plan to pay for the ED services. You say that the enrollee was seen multiple times on this date of 
service. The services are not duplicate. The Plan denied your request. The Plan says that since the enrollee was 
seen for a nosebleed on both occasions, these visits cannot be billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, two physicians from the same practice 
with the same specialty should bill as one physician, unless the EM services are for unrelated problems.  
 
We looked at the file and Medicare rules. While both visits on this date of service were for the treatment of a 
nosebleed, these were distinct events. The enrollee was seen earlier in the day for a nosebleed which was 
successfully treated. The enrollee then went to a separate facility due to a repeat nosebleed later in the day. The 
records also document that this second nosebleed included blood from the tear ducts. While this were 
treatments for the same condition, it was two flare ups of the same condition. These two events were not 
otherwise related. As such, it appears appropriate for these two physicians of the same specialty to each bill for 
the services rendered. Based on this information, we decided that Medicare rules for coverage of the ED 
services have been met. Therefore, we decided that the Plan has to pay for the emergency department (ED) 
consultation provided on March 2, 2023.   
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that  you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the billing department was understaffed. 
The Plan denied your request. The Plan says this 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 laboratory services was not filed until January 18, 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 laboratory services provided on October 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 5, 2022, 
to October 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 5, 2022, to 
October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87476 billed for date of service September 
26, 2022. 
 You asked the Plan to pay for procedure code 87476. The Plan denied your request. The Plan says payment for 
code 87476 is bundled into payment for code 87801. 
 
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 87476 
is a column II code to column I code 87801. 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 procedure code 87476 billed for date of service September 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 80061, 85027) 
provided on February 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that this claim should be covered as in-network. 
The Plan denied your request. The Plan says this claim is not covered OON without a referral. 
 
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 laboratory services (36415, 80053, 80061, 
85027) provided on February 27, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on March 21, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you are requesting reconsideration for the 
denied payment. 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 chiropractic services 
provided on March 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed from February 9, 2022, to March 
2, 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 January 10, 2022. The NOA was not received by the Plan, so no payment 
can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services 
billed from February 9, 2022, to March 2, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95868 billed for date of service May 12, 
2022. 
 You asked the Plan to pay for procedure code 95868. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 95868 is bundled into payment for code 95870. 
 
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 95868 
is a column II code to column I code 95870. 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 procedure code 95868 billed for date of service May 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is being dispensed by a pharmacy to the provider on the enrollee's behalf 
which falls under Medicare Part D coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.  
 
Benefits for Botox may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88342 rendered on January 18, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the claim was billed with diagnosis codes that should not be reported together. 
 
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. The plan has not substantiated their denial in this case. The plan did not submit 
any medical records for these services. There is no way to determine if there's an applicable exclusion for the 
relevant rules. There is no way to determine if the billed diagnosis codes (D12.4 and K63.5) are unrelated to 
each other. Therefore, we decided that the Plan has to pay for procedure code 88342 rendered on January 18, 
2023.  
 
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: 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 the services are medically necessary. The Plan 
denied your request. The Plan says you have exceeded your benefit for the benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 14, 2023, 
through June 3, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The enrollees condition is in fact complex and fragile, and there is every reason to expect that they 
will participate in and benefit from IRF services. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 Resmed Airmini AutoTravel continuous positive 
airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve a Resmed Airmini AutoTravel CPAP. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is meant for travel and therefore not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Resmed Airmini AutoTravel continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-adjunctive non-implanted CGM. 
 
You asked the Plan to pre-approve a CGM. You say that you would rather have a CGM then take insulin. The 
Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 pre-approve a CGM. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that you do not use insulin and you do not 
have low blood glucose levels. The documentation does not show why a finger stick meter would not meet 
your needs. 
 
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 
pre-approve a non-adjunctive non-implanted CGM.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology pan-cancer analysis of minimal residual 
disease (MRD) (the Signatera test). 
 
You asked the Plan to pre-approve Signatera test. You say that you have a family history of cancer. The Plan 
denied your request. The Plan says you do not meet criteria for this testing. 
 
The Plan follows Medicare rules. Medicare rules state that biomarker testing such as Signatera is only covered 
when considered medically 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 Signatera test. Our reviewer says that 
you do not meet criteria for this testing. Our physician reviewer found you have undergone surgery, radiation treatment, and chemotherapy and are reported to be doing very well on aromatase inhibitor therapy. Provided 
records do not document how the results of the testing will directly impact the treatment being delivered to you 
and that a definitive diagnosis remains uncertain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Signatera test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve oncology pan-cancer analysis of minimal residual disease (MRD) (the Signatera test).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed from December 7, 2022, to 
January 5, 2023. 
 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 December 7, 2022. The NOA was not received by the Plan until January 
26, 2023. 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 billed 
from December 7, 2022, to January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service July 18, 
2022.   
You asked the Plan to pay for procedure code 99233. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99233 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 billed for date of service July 18, 2022.