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

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor.  
You asked the Plan to pre-approve the Dexcom G7 sensor. The Plan denied your request. The Plan says  you 
do not meet criteria for the Dexcom G7 sensor. 
 
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 the Dexcom G7 sensor. Our reviewer 
says that the requested Dexcom G7 sensor is not medically necessary. Our physician reviewer found provided 
criteria require insulin use or symptomatic low blood glucose sugar that do not improve with medication 
adjustments. At this time you are not using a medication that causes low blood sugar and is not using insulin. 
 
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 Dexcom G7 sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G7 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99214 billed for date of service September 14, 2022.  
 
You asked the Plan to pay for code 99214. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99214 is not supported by the medical record. The records do not 
support a moderate level of medical decision making or the total time required of the code. 
 
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 99214 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for the code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
 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 code 99214. Our reviewer says that code 99214 is not 
supported by the medical record. Our reviewer found the medical decision making in this case consisted of an 
undiagnosed new problem with uncertain prognosis, no tests/documents, and low medical decision making. 
Medical decision making consisted of recommendations to hydrate, chiropractic, and over the counter 
remedies. Therefore, there is a different code that should have been billed for this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99214 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99214 billed for date of service September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you feel this nutrition 
therapy would be beneficial to you. The Plan denied your request. The Plan says the requested services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device (22612, 22840). 
 
You asked the Plan to pre-approve a Minuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental. More research is needed. 
 
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman device (22612, 22840).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is medically necessary. 
The Plan denied your request. The Plan says a home ventilator is not medically necessary. The patient's needs 
can be met with a bilevel positive airway pressure (BiPAP) device with average volume-assured pressure 
support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has chronic hypoxic and hypercapnic respiratory failure from chronic obstructive pulmonary 
disease.  The provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with 
AVAPS capability and failure of such a device has not been documented.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 26020-F7-F8 x 2 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for code 26020-F7-F8 x 2. You say that the medical records support the billing of 
this code. The Plan denied your request. The Plan says code 26020-F7-F8 x 2 is not supported by the medical 
record. 
 
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 26020 is drainage of tendon sheath, one digit and/or 
palm. 
 
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 code 26020-F7-F8 x 2. Our reviewer says that code 26020 is not supported by the medical record. Our reviewer found the medical record does not state that fluid was 
drained from the tendon sheath(s) during this encounter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 26020-F7-F8 x 2 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 26020-F7-F8 x 2 billed for date of service September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that without a home ventilator, the patient is at 
risk for decompensation and additional hospitalization. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary. The patient's needs can be met with a bilevel positive airway pressure 
(BiPAP) device with average volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee has chronic 
hypoxic and hypercapnic respiratory failure from obstructive pulmonary disease with restrictive physiology 
and interstitial lung disease.  The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with AVAPS capability and failure of such a device has not been documented. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 are needing rehabilitation due to you living 
alone and you cannot stand up without the fear of falling. The Plan denied your request. The Plan says you do 
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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the grocery benefit. 
 
You asked the Plan to pre-approve the grocery benefit. You say that the services are medically necessary. The 
Plan denied your request. The Plan says that in order for you to receive this service, certain criteria must be 
met. You must have both high blood sugar (diabetes) and a condition that affects how you feel (depression or 
depressive disorders). You have diabetes. While you have Post Traumatic Stress Disorder (PTSD), you do not 
have a diagnosis of depression or depressive disorders. 
 
The Plan contract covers a grocery benefit. The Plan contract says members must be diagnosed with both of the 
following conditions to be eligible to receive the grocery benefit from a Plan-specified vendor: diabetes, 
depression or depressive disorders.   
 
We looked at the file and the Plans rules. The files shows that you do not have both of the conditions for 
coverage of the grocery benefit. Based on this information, we decided that the Plans rules for coverage of the 
grocery benefit have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
grocery benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmic biometry (92136) and eye 
exam (92012) provided on February 2, 2023. 
 
You asked the Plan to waive the copayment for the ophthalmic biometry and eye exam. You say that you went 
on January 24, 2023, for an eye exam, paid the $20 copayment, and were called and told you needed to come 
back a few days later. You also say that you feel you should not have to pay an additional copay for the same 
service you already had done. 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 $20 
copayment for medical eye exams under the Vision care benefit category.  
 You have been asked to pay a $20 copayment for the ophthalmic biometry and 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. Therefore, we decided that the Plan does not have to waive the copayment for the 
ophthalmic biometry (92136) and eye exam (92012) provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
(92134), aflibercept injection (J0178), and intravitreal injection of a pharmacologic agent (67028) provided on 
October 21, 2022, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the scanning computerized ophthalmic diagnostic imaging, aflibercept, and 
intravitreal injection. You say that all of the providers are in-network with the Plan. You also say that you 
would like your status to be updated to show that you are in-network with the Plan. The Plan denied your 
request. The Plan says you are not an in-network provider with the enrollee's plan, and the enrollee self-
directed for care. The Plan also says that the enrollee's primary care provider did not refer for services, and no 
medical necessity for an OON provider, such as an urgent or emergency situation, has been documented. 
 
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 scanning computerized ophthalmic diagnostic 
imaging (92134), aflibercept injection (J0178), and intravitreal injection of a pharmacologic agent (67028) 
provided on October 21, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64415-59-RT billed for date of service October 13, 
2022. 
 
You asked the Plan to pay for code 64415. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 64415-59-RT is not supported by the medical records. The 
records show that code 64447 is the code that should be used for the procedure performed.  
 
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 64415 is Injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus. 
 
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 code 64415. Our reviewer says that code 64415 is not supported by the medical record. Our reviewer found the record states that a femoral nerve block was 
performed, not a brachial plexus nerve block. There is a more specific code for 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 code 64415 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 64415-59-RT billed for date of service October 13, 2022.
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. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare 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 with uncomplicated hip fracture repair the enrollee can rehabilitate in a variety of 
settings. Setting has little impact on outcome. The rehabilitation is not intensive or complex. There is no 
indication for frequent physiatry oversight. Admission to IRF criteria is 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 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 are necessary for the enrollee to make 
measurable functional gains as well as improve medical status. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional visits are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the request for ten additional 
occupational therapy visits is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not part of a maintenance program 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain the enrollees current condition or to prevent or slow further deterioration. 
The enrollee had extensive prior therapy, is participating in activities of daily living (ADLs), and has had 
instruction in a home exercise program. The requested additional therapy sessions are not medically necessary 
for the enrollee. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99214) to be provided by an out-of-network (OON) provider.