Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you require continued SNF services. The Plan 
denied your request. The Plan says you do not qualify for any further SNF extensions. 
 
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 that you do not require daily skilled nursing or skilled therapy services. As a practical 
matter, you do not require any skilled services on an inpatient basis, at a skilled level of care as of January 6, 
2024. You do not have any parental medications, complex wound care, or nutrition given via a feeding tube. 
Your function is at or near your new baseline level of function and could be discharged to a lower level of care 
for further 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 continued SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on July 8, 
2023. 
 
You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for the CGM. 
 
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. The documentation indicates that the enrollee did not use insulin or 
had a history of problematic hypoglycemia, or had an in-person visit with their treating physician to evaluate 
their diabetes control and to determine whether the criteria for coverage have been met.  Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on July 8, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 24, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you want the plan 
to charge the urgent care copayment rather than the ER copay, due to needing to go to the closest hospital. 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency care 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 an 
emergency room (ER) visit provided on July 24, 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 requires an IRF level of care. The Plan 
denied your request. The Plan says the services the enrollee needs can be provided in other settings, for 
example a skilled nursing facility (SNF), at home with home health, or at home with physical 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 is functioning at a home care level and does not require intensive 
rehabilitation.  
 
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 moderate sedation services (procedure code 99152) rendered 
on August 18, 2023. 
 
You asked the Plan to pay for moderate sedation services. You say that this should be paid for. The Plan denied 
your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 moderate sedation services. Our reviewer says that the 
service does not meet criteria for approval of payment on this claim. Our reviewer found the enrollee had a T12 
compression fracture and underwent Kyphoplasty. There is no separate sedation record submitted. There is no 
documentation to support the charge. The charge is therefore, deemed not medically reasonable and necessary. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for moderate sedation services (procedure code 99152) rendered on August 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0438 and 36415 provided on May 4, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes G0438 and 36415. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 procedure codes G0438 and 36415 provided on 
May 4, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and related supply allowance. 
 
You asked the Plan to pre-approve a CGM and related supply allowance. You say that you have been a diabetic 
for 21 years and have pricked your fingers testing for that long. The Plan denied your request. The Plan says 
you are not on insulin and there are no documented hypoglycemia episodes. 
 
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 and related supply allowance. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found you are not having 
low blood sugars that we are told of and are not taking medications that typically cause low blood 
sugar. Although CGM might help you and enable you to not need to do finger sticks coverage criteria are not 
met. 
 
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 and related supply allowance have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a CGM and related supply allowance.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the PrismRA genetic test (81479) provided on May 1, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that you have billed the service at issue correctly. The 
Plan denied your request. The Plan says that PrismRA is not a covered benefit. 
 
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 rules also say that for molecular diagnostic tests, such as the test at issue, the MolDX program 
requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are 
met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in 
the DEXTM Diagnostics Exchange. 
 
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 Plan's denial indicates that, according to the DEXTM Diagnostic 
Registry, PrismRA was not covered at the time of service. We are unable to corroborate, nor has the Plan 
provided documentation to support, this finding. It is the Plan's responsibility to support its denial with 
evidence. In this case, the Plan's denial is not supported, so we must find in your favor. Therefore, we decided 
that the Plan has to pay for the PrismRA genetic test (81479) provided on May 1, 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 the enrollee can receive their care in an alternate level of care. 
 
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 clinical documentation shows that enrollee required assistance with mobility and 
activities of daily living in long term care prior to hospitalization currently requiring assistance with mobility 
and self-care tasks. Evaluating therapists recommend return to long term care thus documentation does not 
support daily skilled therapies. Clinical documentation does not specify any daily skilled nursing needs thus 
daily skilled services are not supported. As a practical matter, clinical documentation does not support daily 
skilled services on an inpatient basis in a skilled nursing facility. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pharmacy compounding and 
dispensing services provided from June 2, 2023, to July 10, 2023. 
 
You asked the Plan to waive the coinsurance for the pharmacy compounding and dispensing services. You say 
that you previously had zero cost share for this service. 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 home infusion therapy, including Medicare Part B covered drugs.  
 
You have been asked to pay $300, which is 20% coinsurance of the allowed amount for the pharmacy 
compounding and dispensing services ($1,500 allowed amount x 20% coinsurance = $300). These services fall 
within the home infusion therapy 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 
the pharmacy compounding and dispensing services provided from June 2, 2023, to July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation rides. 
 
You asked the Plan to pre-approve additional transportation rides. You say that you do not have transportation 
for your health needs. You say your health has been worse due to not having the transportation. The Plan 
denied your request. The Plan says the benefit has been exhausted. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation rides.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism-correcting function interocular lens provided 
on July 3, 2023. 
 
You asked the Plan to pay for the astigmatism-correcting function interocular lens. You say that you say your 
doctor told you that you really did not need the astigmatism correcting function intraocular lens and you were 
charged. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism-
correcting function interocular lens provided on July 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 rendered on September 15, 2023. 
 
You asked the Plan to pay for procedure code 64488. You say that this procedure code should be paid for. The 
Plan denied your request. The Plan says only one unit of CPT 64488 should be reported per date of 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 64488 is transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when 
performed). 
 
We asked our coder 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 procedure code 64488. Our reviewer says that this procedure 
code is not supported as billed. Our reviewer found the documentation does not clearly state if the provider 
made one injection or two, however even if the provider made two injections, this code is only billable with 
one unit per coding medically unlikely edit (MUE) guidelines. The documentation provided does not verify 
that this procedure was performed twice. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 64488 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 64488 rendered on September 15, 2023.
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 enrollee requires an LTACH level of 
care and is stable for discharge to that level of care. You say the enrollee clearly meets LTACH criteria based 
on Medicare guidelines. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 Our physician reviewer found the enrollee appears to be receiving all necessary care at the current facility. 
There is no documentation to suggest that the enrollee will receive care at an LTACH that they are unable to 
receive at the current facility, especially regarding specialized transplant team coverage. Therefore, LTACH 
services do not appear to be 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenic stimulators. 
 You asked the Plan to pre-approve osteogenic stimulators. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
approval. 
 
The Plan follows Medicare rules. Medicare rules say that nonunion of long bone fractures is considered to exist 
only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to 
starting treatment with the electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 
sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days. 
 
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 osteogenic stimulators. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found Medicare guidelines advise that 
an osteogenic bone stimulator may be utilized for nonunions of long bones. A nonunion of a long bone fracture 
is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or 
more months prior to starting treatment with the electrical osteogenic stimulator. Serial radiographs must 
include a minimum of two sets of radiographs, each including multiple views of the fracture site, separated by a 
minimum of 90 days. It appears that the most recent x-ray does reveal some bone healing to this fracture site. 
Therefore, the requested osteogenic bone stimulator for this enrollee does not meet the coverage requirements 
for approval. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteogenic stimulators have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteogenic stimulators.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve apligraf skin substitute. 
 
You asked the Plan to pre-approve apligraf skin substitute. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says you do not meet the requirements for approval. 
 
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 apligraf skin substitute. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not demonstrate a failure "to reduce in size by 50% 
after four weeks of standard wound care." Also required for coverage is demonstration of adequate blood flow 
to the wounded area and measures of adequate nutrition. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of apligraf skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve apligraf skin substitute.