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

 
We decided that the Plan does not have to pay for cardiovascular services provided on June 23, 2023. 
 
You asked the Plan to pay for cardiovascular services. You say that supporting documentation was provided. 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 cardiovascular services provided on June 23, 2023.
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 enrollee's clinical conditions meets the full acute 
inpatient rehabilitation criteria. The Plan denied your request. The Plan says the services the enrollee needs can 
be provided safely in other settings, for example, a skilled nursing facility (SNF), 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 the enrollee does not meet coverage criteria for an IRF admission. The enrollee is 
medically stable and does not need a physician's supervision three times a week in an IRF. At the current 
functional level, the enrollee needs routine physical and occupational therapy. The enrollee does not need 
intensive therapies consisting of at least three hours of therapy per day at least five days per week with 
multidisciplinary approach in an IRF. Documentation does not support necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) does not require 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The 
enrollee's rehabilitation needs can be safely provided in a low intensity alternate setting such as continuing in a 
skilled nursing facility (SNF).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 20, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 1, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not enrolled in Medicare as a durable medical 
equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 1, 2023.
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 enrollee needs this care to maximize their level 
of independence. The Plan denied your request. The Plan says medical records do not support the need for an 
IRF admission and, the enrollee needs can be safely provided at another 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 complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service September 
28, 2023.  
 
You asked the Plan to pay for procedure code 87798. You say that the test serves a vital purpose. 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 87798 is 13. The MAI value for this code is 3. You billed 21 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided, were 
correctly coded, and medically necessary. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87798 billed for date of service September 28, 2023.
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 IRF services. The Plan denied your 
request. The Plan says you do not meet the criteria for an IRF admission.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation program provided in an 
IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
April 14, 2023, through May 13, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on April 14, 2023, through May 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a V-GO 40 disposable device. 
 
You asked the Plan to pre-approve an external ambulatory insulin delivery system. You say that this insulin 
delivery system is medically necessary. The Plan denied your request. The Plan says this is not a covered 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. A9274 is not a covered device. Based on this information, we 
decided that Medicare rules for coverage of an external ambulatory insulin delivery system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a V-GO 40 disposable device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory pathogen panel testing provided on February 8, 
2023. 
 
You asked the Plan to pay for panel testing. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this testing was not billed with appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panel tests must be billed 
with a single unit of service and must not be unbundled and billed as individual components.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate testing. Based on this 
information, we decided that Medicare rules for coverage of panel testing have not been met. Therefore, we 
decided that the Plan does not have to pay for respiratory pathogen panel testing provided on February 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on June 
06, 2023. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you had not been charged 
a coinsurance for the injection before. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the in-
network Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a denosumab injection provided on June 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376 billed for date of service June 16, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the claim was correctly coded. The Plan denied 
your request. The Plan says there was no order for the service. 
 
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 76376 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation. 
 
We find that CPT code 76376 is not supported in the medical record. The radiology report does not document 
whether the 3D rendering was performed on an independent workstation or on the acquisition scanner. The 
records do not include a separate report for the 3D rendering. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 76376 billed for date of service June 16, 2023.
Appeal type: Hospice
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inpatient care provided from September 1, 2023, to September 2, 
2023. We also decided that the Plan does not have to pay for the inpatient care provided from August 30, 2023, 
to August 31, 2023.  
 
You asked the Plan to pay for inpatient hospital care provided from August 30, 2023, to September 2, 2023. 
You say that the enrollee's hospice was terminated upon hospital admission. The Plan says that Original 
Medicare is responsible for payment. 
 
We decided that the Plan has to pay for the inpatient care provided from September 1, 2023, to 
September 2, 2023.  
 
The Plan follows Medicare rules. Medicare rules say that Original Medicare, not the Plan, is responsible for all 
Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The 
rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The file shows that hospice care ended on August 30, 2023. Since Original Medicare is responsible for 
coverage through the end of the month in which hospice was terminated, the Plan is responsible for services 
provided from the beginning of the following month. Therefore, we decided that the Plan has to pay for the 
inpatient care provided from September 1, 2023, to September 2, 2023.  
 
We also decided that the Plan does not have to pay for the inpatient care provided from August 30, 2023, 
to August 31, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that Original Medicare, not the Plan, is responsible for all 
Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The 
rules say that the Plan may direct the provider to bill Medicare directly for these services. 
 
The file shows that hospice care ended on August 30, 2023. This means that Original Medicare is responsible 
for services through the end of the month in which hospice care was terminated. Therefore, we decided that the 
Plan does not have to pay for the inpatient care provided from August 30, 2023, to August 31, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 02, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are requesting 
reconsideration of the copayment applied to the claim. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for the ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on September 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on August 29, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you do not agree with the denial of payment, 
we have sent all the appropriate documents. The Plan denied your request. The Plan says that you are not 
enrolled in Medicare as a durable medical equipment supplier. Therefore, the claim was denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 1, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 1, 2023.
Appeal type: Hospice
Decision: Partially Favorable

 
We decided that the Plan has to pay for services provided from November 1, 2023, to November 17, 2023.. We 
decided that the Plan does not have to pay for services provided from October 19, 2023, to October 31, 2023..  
 
You asked the Plan to pay for home health services provided from October 19, 2023, to November 17, 2023. 
You say that the enrollee was not on hospice at the time of service. The Plan says that Original Medicare is 
responsible for payment. 
 
We decided that the Plan has to pay for services provided from November 1, 2023, to November 17, 
2023..  
 
The Plan follows Medicare rules. Medicare rules say that Original Medicare, not the Plan, is responsible for all 
Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The 
rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The file shows that hospice care ended on October 18, 2023. Since Original Medicare is responsible for 
coverage through the end of the month in which hospice ended, the Plan is responsible for services provided 
from the beginning of the following month. Therefore, we decided that the Plan has to pay for services 
provided from November 1, 2023, to November 17, 2023..  
 
We also decided that the Plan does not have to pay for services provided from October 19, 2023, to 
October 31, 2023.. 
 
The Plan follows Medicare rules. Medicare rules say that Original Medicare, not the Plan, is responsible for all 
Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The 
rules say that the Plan may direct the provider to bill Medicare directly for these services. 
 
The file shows that hospice care ended on October 18, 2023. This means that Original Medicare is responsible 
for services provided through the end of the month in which hospice ended. Therefore, we decided that the Plan 
does not have to pay for services provided from October 19, 2023, to October 31, 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.