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

 
We decided that the Plan does not have to pay for practitioner services provided on January 19, 2023, billed 
with procedure codes 96365-59, 96366-59 (2 units), 96521, and G0108. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 96365-59, 96366-59 (2 units), 96521, and G0108 is 
intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1-hour, 
intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure), refilling and maintenance of portable pump, and 
diabetes outpatient self-management training services, individual, per 30 minutes.  
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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the codes in question are not 
supported by the medical record. The record states that a continuous insulin infusion was performed with 
guidance by glucose measurements. According to CPT rules, there is a more specific code to report this 
procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 19, 2023, billed with procedure 
codes 96365-59, 96366-59 (2 units), 96521, and G0108.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic eye exam (92014). 
 
You asked the Plan to waive the copayment for the diagnostic eye exam. You say that the services should be 
covered. 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 $30 
copayment for vision care.  
 
You have been asked to pay a $30 copayment for the diagnostic eye exam. This item/service falls within the 
vision 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.  Your complaint is not a valid appeal for medical coverage. After looking at all of the information in this case, 
we found that you do not owe any money for the vision services. Since you owe no money, there is no need for 
a coverage decision. 
 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly. 
 
Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic eye exam (92014).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an initial hospital inpatient or observation care, per day 
(99222) and subsequent hospital inpatient or observation care, per day (99231) provided on March 15, 2023, to 
March 16, 2023. 
 
You asked the Plan to pay for hospital care. You say that you request reconsideration and have submitted 
medical records for review. The Plan denied your request. The Plan says the enrollee was registered in an 
outpatient hospital. 
 
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 find that CPT code 99222, 99231 is not supported in the medical record. Specifically, the enrollee was 
registered in an outpatient hospital, therefore, an inpatient place of service 21 cannot be billed. Based on this 
information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for an initial hospital inpatient or observation care, per day (99222) 
and subsequent hospital inpatient or observation care, per day (99231) provided on March 15, 2023, to March 
16, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a CGM. You say that the enrollee needed this CGM. The Plan denied your 
request. The Plan says that the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a CGM. Our reviewer says that a CGM is 
medically necessary. Our physician reviewer found the enrollee is taking insulin; therefore, a CGM is 
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 a CGM have been met. Therefore, we decided that the Plan has to pay for a 
continuous glucose monitor (CGM).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON office visit. You say that the enrollee has been on weekly 
immunotherapy injections for several years, and approval was never required. You say that the medical records 
provided support that the services provided were medically necessary.  The Plan denied your request. The Plan 
says services from non-participating providers are not covered unless pre-authorized.  
 
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 an office visit provided on January 18, 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 group 2 standard power wheelchair (K0823) and 
additional items and accessories (codes K0195 x2, E2361, K0015 x2, and K0019 x2). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that you are unable to perform MRADLs in the home and/or community without a powered 
wheelchair. You also say that you are unable to walk more than a block yourself. The Plan denied your request. 
The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 group 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that you do not meet the criteria for coverage. Our 
physician reviewer found you are able to walk three blocks without an assistive device. Our reviewer also 
found that you do not require a power wheelchair to perform MRADLs in the home. 
 
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 group 2 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0823) and additional items and accessories (codes K0195 x2, E2361, K0015 x2, and K0019 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve a Freestyle Libre 2. You say that the requested item is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
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 Freestyle Libre 2. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the records do not mention why 
fingerstick monitoring would not suffice for the enrollee at this time. It has been determined that the enrollee 
does not meet criteria for CGM coverage. 
 
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 Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 2.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets.  
You asked the Plan to pre-approve the medication. You say that you are appealing this denial. 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. Although the ondansetron requested is an oral anti-emetic drug that may be covered by 
Medicare Part B, the requested use does not fall within Medicare Part B coverage because the record does not 
show that it will be administered as a full therapeutic replacement for intravenous anti-emetics for a particular 
chemotherapy regimen, initialed within 2 hours of the administration of the chemotherapeutic agent, and 
continued for a period not to exceed 48 hours from that time. Therefore, we decided that the Plan does not have 
to pre-approve ondansetron tablets.  
 
Benefits for the medication 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: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81162, 81201, 81218, 81292, 81295, 81298, 
81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 81272, 81479) provided on March 20, 2023. 
 
You asked the Plan to pay for genetic testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that NGS testing may be covered when the criteria in the 
Medicare rules section of this letter have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the provided medical records do not support a 
cancer diagnosis or a personal history of a qualifying cancer. Therefore, we decided that the Plan does not have 
to pay for genetic testing (81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 
81314, 81334, 81345, 81272, 81479) provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on October 13, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. 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 nursing facility care 
provided on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, 
per session (99183x20). You asked the Plan to pre-approve hyperbaric oxygen therapy (HBOT). You say that you are requesting 
reconsideration for the denial. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show the enrollee does not have failure of standard wound therapy for this 
wound. 
 
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 hyperbaric oxygen therapy (HBOT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the review indicates that the enrollee has a diabetic foot ulcer on the 
big toe. The record sent by the provider indicates that the wound is slowly healing with the current wound care. 
On June 15, 2023, the wound surface area was 0.28 square (sq) centimeter (cm), and this decreased to 0.04 sq 
cm. by August 23, 2023. The measurements decreased from June 15, 2023, 0.7 cm x 0.4 cm x 0.2 cm, to on 
August 23, 2023, 0.2 cm x 0.2 cm x 0. 2 cm. This August 23, 2023, status is documented as "86%" wound 
healing. The review has determined that the records do not show a failure of standard wound therapy for this 
wound. The wound is making steady progress (86% healed) in two months. The review has determined that the 
enrollee does not meet criteria for approval of HBO. HBO is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy (HBOT) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute 
interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, per session 
(99183x20).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care services provided on October 26, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there was no prior authorization for the services 
provided.  
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 nursing facility care services provided on 
October 26, 2022, by an out-of-network (OON) provider.
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 are medically necessary for you to return 
to your prior level of function. The Plan denied your request. The Plan says the records show that there is no 
need for an intensive rehabilitation program. 
 
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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 21, 2022, to 
September 19, 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 NOA was not received by the Plan and no payment can be made on this claim. Therefore, we 
decided that the Plan does not have to pay for home health services provided from August 21, 2022, to 
September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 9, 2023, billed with 
procedure codes L8679, 64555, 64999-59, and 99345-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes L8679, 64555, 64999-59, and 99345-25 is implantable 
neurostimulator, pulse generator, any type, percutaneous implantation of neurostimulator electrode array; 
peripheral nerve (excludes sacral nerve), unlisted procedure, nervous system, and home or residence visit for 
the evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. 
 
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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the procedure report does not include 
documentation to support codes L8679, 64555, and 64999. Evaluation and management service provided does 
not support high level of medical decision making and therefore code 99345 cannot be verified. Procedure 
includes moderate level of decision making. There is a more appropriate code to report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 9, 2023, billed with procedure codes 
L8679, 64555, 64999-59, and 99345-25.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick injector pen. 
 
You asked the Plan to pre-approve the medication. You say that you are requesting an exception to this 
exclusion. 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 Repatha Sureclick injector 
pen.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.