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

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre sensor kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre sensor kit. You say that monitoring blood sugar can be 
helpful to a diabetic patient. The Plan denied your request. The Plan says The use of continuous glucose 
monitoring (CGM) in members with type 2 diabetes who do not require three or more insulin injections per day 
or do not require an insulin pump is considered to be investigational. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the FreeStyle Libre sensor kit have 
been met. The Plan submitted all the documents from the provider and the outreach attempts were completed to 
try and get additional information. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) (99183, G0277). You asked the Plan to pre-approve HBOT. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the request is not medically necessary because the records do not show failure of 
standard wound care as there is no vascular assessment and correction of identified vascular problems in the 
affected limb. 
 
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 HBOT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has type 2 diabetes and a right heel ulcer. Additional diagnoses are coronary artery 
disease, previous myocardial infarction, carotid artery disease, chronic kidney disease, and congestive heart 
failure. The right heel ulcer resulted from pressure injury during a stay in a nursing home. Under wound care 
for more than 30 days, the wound progressed to Wagner grade 3, despite standard wound care with repeated 
debridement, and treatment of infection. However, the medical record does not include assessment of vascular 
status of the involved limb. The record includes a statement, "unable to get ABIs due to RLS."  Presumably 
ABI is ankle brachial index and RLS is right leg swelling. However, there are no descriptions of pulses or 
doppler assessments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy (HBOT) (99183, G0277).
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 need therapy services to regain your daily 
functions and around the clock assistance. The Plan denied your request. The Plan says the services you need 
can be provided safely in another setting such as a skilled nursing facility, home with home health services or 
home with outpatient therapy.  
 
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 you do not require treatment by multiple therapies. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 26, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen in good faith. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. 
 
 
 We find that CPT code 99223 is not supported in the medical record. Specifically, the records do not support a 
comprehensive history. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 
billed for date of service August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), comprehensive oral 
evaluation - new or established patient (D0150), and bitewings - four radiographic images (D0274) provided on 
January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial as the provider is 
in-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. The Plan also says the provider's contract 
was not effective with your plan when the services were rendered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a prophylaxis - adult (D1110), comprehensive oral evaluation - new or established patient (D0150), 
and bitewings - four radiographic images (D0274) provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested device was prescribed to the 
enrollee to help manage complex respiratory needs at home. This is medically necessary and will increase the 
enrollee's ability to move during therapy and adherence to his therapy plan. The Plan denied your request. The 
Plan says the request is not medically necessary because the records show the enrollee does not have a 
qualifying diagnosis, such as bronchiectasis in the setting of COPD. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found provided records in this case do not document 
the enrollee has cystic fibrosis, bronchiectasis, or one of the neuromuscular diseases for which a high frequency 
chest wall oscillation device may be covered. Provided records in this case also do not document the enrollee 
presently uses a mechanical in-exsufflation device (E0482) and plans to continue to do so. The records in this 
case do not clearly document failure of all standard treatments to adequately mobilize retained secretions. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from March 2, 2023, to 
March 6, 2023.  
 
You asked the Plan to pay for the medication. You say that this was a 72-hour hold for elderly safety and was 
deemed necessary. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from March 2, 2023, to March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous, osteoperiosteal, or cartilage graft of the mandible or 
maxilla (D7950), and guided tissue generation (D4266) provided on February 7, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for osseous, 
osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950), and guided tissue generation (D4266) 
provided on February 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tremfya solution pen 100mg. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed non-biologic 
systemic therapies and the requested medication is expected to improve their condition substantially. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tremfya solution pen 
100mg.  
 
Coverage for Tremfya may be available through the enrollees Medicare Part D prescription drug benefits.  
Please contact the plan that administers the enrollees Medicare Part D benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92014), and an eye refraction (92015) 
provided on January 4, 2023, by an out-of-network provider.  
You asked the Plan to pay for the vision services. You say that the services should be covered. The Plan denied 
your request. The Plan says these services are not covered out-of-network. 
 
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 when you utilize an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
an eye examination (92014), and an eye refraction (92015) provided on January 4, 2023, by an out-of-network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you can benefit from an acute inpatient rehabilitation 
that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs can be met in other settings.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary.  
The Plan denied your request. The Plan says when you are ready to leave the hospital, you can safely receive 
this care in another setting. 
 
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 that you do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 the services will increase the enrollee's mobility and 
endurance before returning home. The Plan denied your request. The Plan says ongoing skilled care can be 
provided in an alternative setting.  
 
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 enrollee does not require treatment by multiple therapies. 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services would greatly improve the enrollee's 
functional abilities to allow them to return to their baseline. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria 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 the enrollee does not require treatment by multiple therapies. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A0431 and A0436 billed for date of service 
September 13, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee required transport to the closest 
facility. The Plan denied your request. The Plan says the services are denied when billed with a GZ modifier. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that codes A0431 and A0436 were billed with a GZ modifier. claim lines items submitted with a GZ 
modifier shall be denied automatically. Based on this information, we decided that Medicare rules for coverage 
of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes A0431 and A0436 billed for date of service September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from September 2, 2022, 
to September 6, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
documentation in the medical record clearly supports the clinical diagnosis and the documentation supports the 
DRG as billed. The Plan denied your request. The Plan says diagnosis code I21.A1 is not supported, which 
resulted in a DRG change. 
 
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 I21.A1, defined as Myocardial infarction type 
2. 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 diagnosis code I21.A1 is not sufficiently supported. Our physician 
reviewer found the enrollee was treated in the hospital with hypotension. Troponins were mildly elevated, and 
no other signs or symptoms of acute coronary syndrome were noted. The electrocardiogram findings described 
ischemia or infarction. The clinical picture as a whole described a troponin leak not Myocardial infarction.  
 
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 from September 2, 2022, to September 6, 2022, at the DRG originally 
billed.
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 the enrollee can receive the care needed in another setting, such as at home, 
in a long-term care facility, or other outpatient setting.  
 
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 clinical documentation shows that evaluating therapists recommend skilled 
therapy 3-5 days per week and that the enrollee is not below functional baseline. No specific recommendation 
for frequency of skilled nursing provided, however there are no documented daily skilled nursing needs, the 
enrollee would not be expected to require daily skilled 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.