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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99309 for 
date of service November 15, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
In this case, the CPT Code Manual definition of code 99309 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility floor or unit. 
 
We find that CPT code 99309 is not supported in the medical record. Specifically, this service was billed with 
diagnosis code F06.32 (mood disorder due to known physiological condition with major depressive-like 
episode). This diagnosis has a code first note indicating that another code should be billed as the primary/first-
listed diagnosis on the claim. This claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the subsequent nursing facility care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care services coded 99309 for 
date of service November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on November 01, 2022. 
 
You asked the Plan to pay for the office visit (99214). You say that the service was medically necessary. 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 office visit (99214) 
provided on November 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computer assisted surgical navigational procedure (20985) 
provided on September 01, 2022. 
 
You asked the Plan to pay for computer assisted surgical navigational procedure (20985). You say that the 
service was medically necessary. 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 computer assisted 
surgical navigational procedure (20985) provided on September 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve Freestyle Libre 3. You say that you need to have this to check your blood 
sugar level. The Plan denied your request. The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested SNF services are not reasonable and 
necessary for the treatment of the enrollee's illness or injury. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the enrollee needs this device and 
procedure due to her worsening heart failure. The Plan denied your request. The Plan says the CardioMEMS 
device has been determined to be of uncertain value in the most recent 2022 ACC/AHA Guidelines and carries 
a risk of significant complications including death and severe pulmonary artery injury. 
 
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 CardioMEMS HF system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of 
a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of enrollees with CHF. The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee population with preserved ejection fraction and was somewhat limited in 
scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure 
symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's clinical management. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system (33289, C2624).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve Minuteman. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental/investigational. 
 
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 Minuteman. 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 Minuteman have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman procedure.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the cost share amount for the outpatient services provided from July 27, 
2022, to August 4, 2022. 
 
You asked the Plan to waive the cost share amount for the outpatient services. You say that you paid your full 
annual out-of-pocket cost of $7,550 for covered services on September 1, 2022. You also say that you should 
not be responsible for any additional copayments. The Plan denied your request. The Plan says that the 
maximum-out-of-pocket (MOOP) has not been reached. 
 
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 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 has not provided documentation to support when the 
maximum-out-of-pocket (MOOP) was reached. Therefore, we decided that the Plan has to waive the cost share 
amount for the outpatient services provided from July 27, 2022, to August 4, 2022.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the glucose test strips (A4253) provided on November 28, 2022. 
 
You asked the Plan to pay for the test strips. The Plan denied your request. The Plan says that the 
documentation does not contain a proof of delivery for these items. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the documentation did not contain a proof of delivery for 
these items. However, the additional information submitted by the Plan contains a valid proof of delivery and 
order for the test strips and date of service in question. Therefore, we decided that the Plan has to pay for the 
glucose test strips (A4253) provided on November 28, 2022.  
 
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 the collection, venous blood, venipuncture (36415), office or 
other outpatient visit for the evaluation and management of a new patient (99205), and measurement, post-
voiding residual urine and/or bladder capacity, us, non-imaging (51798), provided by opted out provider, 
rendered on date of service January 30, 2023. 
 
You asked the Plan to pay for the collection, venous blood, venipuncture, office or other outpatient visit for the 
evaluation and management of a new patient, and measurement, post-voiding residual urine and/or bladder 
capacity, us, non-imaging. You say that the services were medically necessary. The Plan denied your request. 
The Plan says the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
collection, venous blood, venipuncture (36415), office or other outpatient visit for the evaluation and 
management of a new patient (99205), and measurement, post-voiding residual urine and/or bladder capacity, 
us, non-imaging (51798), provided by opted out provider, rendered on date of service January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetics testing rendered on November 21, 
2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
testing was not medically necessary. Our physician reviewer found the enrollee has diagnoses of generalized 
anxiety disorder and Alzheimer's disease. The records do not document consideration of a specific drug 
treatment that has gene-drug interactions for which a pharmacogenetics panel 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the pharmacogenetics testing rendered on November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to approve a referral to a provider who has opted out of Medicare. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue are for a non-urgent, non-emergent situation from a provider who has opted out of the 
Medicare program. Therefore, we decided that the Plan does not have to approve a referral to a provider who 
has opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the right 
shoulder. 
 
You asked the Plan to pre-approve the MRI of the right shoulder. You say that the MRI is necessary to help 
determine the treatment plan for the enrollee. The previous MRI was ordered by a different physician and was 
not performed. The Plan denied your request. The Plan says that there are no notes that the MRI that was 
already approved was done. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the right shoulder. Our 
reviewer says that the MRI is not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the magnetic resonance scan that was approved on February 
14, 2023, has been performed. The requested scan can be performed using the authorization from February 14, 
2023. Another scan in addition to this one does not meet Medicare criteria for 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 the MRI of the right shoulder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the right shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with a neurologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that your condition has progressed, and you are 
having more off times with an increase in symptoms. You are requesting deep brain stimulation with the 
requested provider. The Plan denied your request. The Plan says there is no medical necessity for an OON 
provider when in-network providers are available. You must use in-network providers to receive services/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 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 (99205) with a neurologist to be provided 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 you are appealing the denial of IRF admission. The 
Plan denied your request. The Plan says that you do does not meet the guidelines for Inpatient Rehab Facility 
services. 
 
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 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 at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. You have had a mild decline from your baseline level of function and may benefit from 
therapy and assistance, but you do not require the intensity of therapies provided in acute inpatient 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart System (0408T, C1824, C1898). 
 
You asked the Plan to pre-approve an Optimizer smart system. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the requested procedure is considered 
experimental, investigational or unproven, in which Medicare and the Plan do not cover. 
 
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 an Optimizer smart system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found an exhaustive review of the current medical literature pertaining to the 
CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several 
randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the 
data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and 
objective functional capacity. While the clinical studies led to FDA approval in 2019, CCM remains the subject 
of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit. At the current time, the medical reviewer would not consider the CCM system to 
be medically necessary in this 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 an Optimizer smart system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart System (0408T, C1824, C1898).