Persius/hicric huggingface dataset:
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 would like the request for an IRF admission to 
be approved. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 13, 2023, billed with 
procedure code 71046. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 The Plan must follow Medicare rules. Medicare rules say that Radiologic examination of the chest (chest X-
ray) are only covered when medically necessary. They must be billed with a valid diagnosis from the list of 
diagnoses that support medical necessity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim has not been billed with a diagnosis 
from the list of diagnoses that support medical necessity. Therefore, we decided that the Plan does not have to 
pay for imaging services provided on February 13, 2023, billed with procedure code 71046.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested device is 
needed for your quality of care. The Plan denied your request. The Plan says you do not meet criteria for the 
requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 rendered on March 14, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations.  
 
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 88305 is not supported in the medical record. Specifically, payment for this service 
would be included in the payment for the facility. Based on this information, we decided that Medicare rules 
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88305 rendered on March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom G7 continuous glucose monitor and supply allowance. 
 
You asked the Plan to pre-approve the Dexcom G7 continuous glucose monitor and supply allowance. You say 
that you prefer the Dexcom G7 CGM since you are fearful of needles. You also say it would be convenient for 
you to use the monitor rather than to prick your fingers to read your sugar levels.  The Plan denied your 
request. The Plan says that you do not meet the criteria for the CGM and supply allowance. 
 
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 pre-approve the Dexcom G7 continuous glucose 
monitor and supply allowance. Our reviewer says that the CGM and supply allowance are medically necessary. 
Our physician reviewer found the enrollee is not able to check her blood glucose sugar with the fingerstick 
method due to a fear of needles/lancets. The enrollee's A1C is above goal and likely would be improved if she 
had some sense of when and why her blood glucose sugars rise. The CGM would help with this. 
 
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 continuous glucose monitor and supply allowance have been 
met. Therefore, we decided that the Plan has to pre-approve a Dexcom G7 continuous glucose monitor and 
supply allowance.  
 
 
 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on February 14, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on February 14, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a behavioral health assessment provided on 
November 08, 2022. 
 
You asked the Plan to waive the copayment for a behavioral health assessment. You say that you never had a 
test or assessment. 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 $10 
copayment for other outpatient diagnostic tests. 
 
You have been asked to pay a $10 copayment for a behavioral health assessment. This item/service falls within 
the other outpatient diagnostic tests 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. However, since the allowed amount is less than the standard copayment, you 
only owe $8.68. Therefore, we decided that the Plan does not have to waive the copayment for a behavioral 
health assessment provided on November 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (99284) provided on 
February 10, 2023. 
 
You asked the Plan to pay for 99284. You say that this was medically necessary. The Plan denied your request. 
The Plan says diagnosis codes F12.959 and F12.20. 
 
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 99284 is emergency department visit. 
 
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 99284. Our reviewer says that this code does not meet 
criteria for payment with the diagnosis codes billed. Our reviewer found you reported diagnosis codes F12.959 and F12.20. Per coding guidelines, diagnosis code F12.959 has an "Excludes 1" with code F12.20. These 
diagnosis codes contradict each other and cannot be reported together. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99284 have not been met. Therefore, we decided that the Plan does not have to 
pay for an emergency department visit (99284) provided on February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E2361, 
E2377, E2313, K0108x2, E1028x3, E1007, E2620, E0955, E0978, E1012, K0040x2, E2311, E0956, E2624). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has several 
medical conditions and needs a custom wheelchair to complete daily activities. The Plan denied your request. 
The Plan says the requested wheelchair must be requested with the correct code. The upgraded electronics are 
not medically necessary, and the joystick module controller display is included with the requested controller. 
 
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 looked at the file and Medicare rules. The records show that the code used does not match the power 
wheelchair requested. Approval is subject to correct coding. Due to the denial of the wheelchair, the 
accessories requested are not covered. Based on this information, we decided that Medicare rules for coverage 
of a power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power wheelchair and accessories (K0861, E2361, E2377, E2313, K0108x2, E1028x3, E1007, 
E2620, E0955, E0978, E1012, K0040x2, E2311, E0956, E2624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care evaluation and management (99291) provided 
on January 1, 2023. 
 
You asked the Plan to pay for 99291. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says diagnosis codes J96.90 and J95.821 should not be reported together. 
 
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 99291 is critical care evaluation and management. 
 
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 99291. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found you reported diagnosis codes J96.90 and J95.821. Per coding 
guidelines, there is an "Excludes 1" note between these two diagnosis codes. Billing both diagnosis codes is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99291 have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care evaluation and management (99291) provided on January 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 12, 2022 to July 11, 
2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. 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 start of care date is June 12, 2022. The NOA was not received by the Plan until September 26, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on June 12, 2022 to July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 27, 2023. 
 
You asked the Plan to pay for the office visit. You say that this provider was the only available provider to 
render the services via tele video and since the patient is a homebound patient due to COVID -19 he couldn't 
leave his house to go to a provider that is in-network. You say that it was highly medically necessary for the 
provider to perform this service to the patient. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available and requires authorization for certain services. No 
medical necessity for an out-of-network provider such as an urgent or an emergent situation that 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this level of care. The Plan denied 
your request. The Plan says the enrollee does not meet 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 the enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees care needs can be met at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subcute and pharmacy services provided on April 29, 
2022, to April 30, 2022. 
 You asked the Plan to pay for the subcute and pharmacy services. 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 subcute and 
pharmacy services provided on April 29, 2022, to April 30, 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 enrollee does meet the admission criteria for IRF. 
The Plan denied your request. The Plan says the denial of IRF care is correct. 
 
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 not shown to require 15 hours per week of rehabilitative services and 
regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
provided on February 04, 2023. 
 
You asked the Plan to pay for a continuous positive airway pressure (CPAP) device. You say that prior 
authorization is not required for this item. 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 a continuous positive 
airway pressure (CPAP) device provided on February 04, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ablation of the prostate, and related services provided on 
February 16, 2023. 
 
You asked the Plan to pay for an ablation of the prostate, and related services. You say that the provider was 
unaware that the services required authorization. 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 an ablation of the 
prostate, and related services provided on February 16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
January 06, 2023, to January 07, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you should not be 
charged for two emergency room visits. 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 $65 
copayment for emergency care. 
 
You have been asked to pay a $65 copayment for the emergency room services. 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 the emergency room 
services provided on January 06, 2023, to January 07, 2023.