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

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you request to see this provider. The Plan 
denied your request. The Plan says this provider is out-of-network, and the services could be performed in-
network. 
 
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 to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service July 29, 2022. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says the testing 
exceeds the enrollee's needs. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The file shows that a urinary tract infection panel was provided. The 
medical records from the treating physician show that a urinalysis was ordered. The medical records do not 
document the panel testing as part of the treatment plan, or document how the results of panel testing will 
impact clinical management. Based on this information, we decided that there is insufficient information in the 
record to determine if Medicare rules for coverage of the billed testing have been met. . Therefore, we decided 
that the Plan does not have to pay for the lab testing billed for date of service July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laser hair removal (17999). 
 
You asked the Plan to pre-approve laser hair removal. You say that laser hair removal is not a cosmetic 
procedure. The Plan use to cover a cream for your skin condition and did not consider that cosmetic The Plan 
denied your request. The Plan says the request for laser hair removal is considered a cosmetic procedure and is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laser hair removal have not been met. Therefore, we decided that the Plan does not have to pre-
approve laser hair removal (17999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you want to see this provider because it was 
recommended. The Plan denied your request. The Plan says this provider is out-of-network, and the services 
could be performed in-network. 
 
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 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 pay for the initial hospital inpatient care (99222) provided on 
January 26, 2023. 
 
You asked the Plan to pay for the initial hospital care. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says that the initial hospital evaluation was done the day prior to 
the surgery. CPT code 33208 has a global surgery period of 90 days, which also includes the day prior to the 
surgery. CPT Code 99222 is included in surgery code 33208. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that evaluation and management services provided the day before a major surgical procedure are 
not included in the global payment, but these services must be reported with modifier -57. CPT code 99222 was not billed with an appropriate modifier to allow separate payment the day before a major 
surgery described by code 33208. Based on this information, we decided that Medicare rules for coverage of 
initial hospital care have not been met. 
 
We find that CPT code 99222 is the initial hospital inpatient care. CPT code 99222 was not billed with an 
appropriate modifier to suggest this was not related to code 33208. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for the initial hospital inpatient care (99222) provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve medically tailored meals. 
 
You asked the Plan to pre-approve medically tailored meals. The Plan denied your request. The Plan says that 
the coverage criteria are not met. 
 
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 coverage criteria are not met. However, the Plan has not 
provided medical records showing that the coverage criteria are not met. Additionally, the Plan contract only 
states that medically tailored meals are offered, but not state any coverage criteria for this benefit. The Plan has 
submitted a coverage criteria document with the case file, but has not shown that this document is public and 
accessible to the enrollee. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pre-approve medically tailored meals.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 10, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the requested CGM is medically necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for authorization from the enrollees 
physician indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia Based 
on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis bio-engineered skin substitute (15275, Q4158). 
 
You asked the Plan to pre-approve Kerecis bio-engineered skin substitute. You say that this skin graft is 
recommended for optimal healing. The Plan denied your request. The Plan says this product is 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 Kerecis bio-engineered skin substitute. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the use of skin graft is not medically necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kerecis bio-engineered skin substitute have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Kerecis bio-engineered skin substitute (15275, Q4158).
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 the enrollee cannot live alone and does not have a 
place to live if they were let out of rehab. The Plan denied your request. The Plan says the SNF services are not 
medically necessary. 
 
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 You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in an 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: 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 IRF services to regain her 
maximum function. The Plan denied your request. The Plan says the enrollee does not meet the requirements 
for an IRF admission.  
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement. However, the documentation does not 
support that she would meet criteria for admission to an IRF. The enrollee can receive further services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacral nerve neurostimulator. 
 
You asked the Plan to pre-approve a sacral nerve neurostimulator. You say that the patient has tried and failed 
multiple medications without improvement of urinary symptoms. The Plan denied your request. The Plan says 
the requested sacral nerve neurostimulator is not medically necessary. 
 
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 sacral nerve neurostimulator. Our 
reviewer says that the requested sacral nerve neurostimulator is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the records have not shown that the enrollee has non-
neurogenic overactive bladder or that he does not have obstructive uropathy. 
 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 sacral nerve neurostimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a sacral nerve neurostimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with enclosed frame (identified with code 
E0144). 
 
You asked the Plan to pre-approve a walker with enclosed frame. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for a walker with an 
enclosed frame (E0144) has not been established. 
 
We looked at the file and Medicare rules. Review of the file shows that the item at issue is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of a walker with enclosed 
frame have not been met. Therefore, we decided that the Plan does not have to pre-approve a walker with 
enclosed frame (identified with code E0144).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator provided on June 27, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the home ventilator. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says this item is not covered when received by an out-
of-network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network durable medical equipment is not covered. 
 
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 this item. Therefore, we 
decided that the Plan does not have to pay for the home ventilator provided on June 27, 2023, by an OON 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 1, 2023, to May 
10, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.81, described as 
Sepsis due to Enterococcus. 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 the inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found that the documentation revealed the enrollee with mental status at baseline, 
normal creatinine, normal blood pressure, no oliguria, and normal platelet count but bilirubin was 1.8 on 
presentation, which is a SOFA of 1 and insufficient to meet Sepsis 3 criteria. There was insufficient evidence 
of organ failure directly related to a dysregulated response to systemic infection to justify the code, A41.81.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on May 1, 2023, to May 10, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70450 billed for date of service June 7, 2023. 
 
You asked the Plan to pay for procedure code 70450. You say that procedure code 70450 was coded with the 
appropriate modifier and the claim should be reconsidered for payment. The Plan denied your request. The 
Plan says that payment for code 70450 is bundled into payment for code 70496. 
 
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 says that payment for code 70450 is bundled into payment for code 
70496. However, documentation was not submitted supporting that procedure code 70496 was billed on the 
same day by the same provider. This means that procedure code 70450 cannot be considered inclusive and is 
separately payable. Therefore, we decided that the Plan has to pay for procedure code 70450 billed for date of 
service June 7, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that the occupational therapist recommended the 
bed due to the enrollee's mobility issues. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and segmental 
pneumatic appliance for use with pneumatic compressor (E0667) to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance for use with 
pneumatic compressor 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 
a pneumatic compressor (E0651) and segmental pneumatic appliance for use with pneumatic compressor 
(E0667) to be provided by an out-of-network (OON) provider.