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

 
We decided that the Plan does not have to pay for practitioner services provided on April 6, 2021, billed with 
evaluation and management (EM) code 99219. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. The claim was inappropriately billed with pos 
21 as documentation states that the patient was in observation on the date of service in question. Therefore, we decided that the Plan does not have to pay for practitioner services provided on April 6, 2021, billed with 
evaluation and management (EM) code 99219.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64680 billed for date of service June 15, 
2023.  
 
You asked the Plan to pay for procedure code 64680. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64680 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64680 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64680 billed for date of service June 15, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 documentation does not support that you require skilled nursing services with the 
specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide care 
only in a SNF. You do not have complex wound care, intravenous (IV) antibiotics, enteral feedings or other 
skilled nursing need that require a SNF admission. Your functional level does not require the skills of a 
professional therapist only in a SNF. You do not require skilled nursing or skilled therapy on a daily basis. As a 
practical matter, your needs do not require the necessary services on an inpatient basis in a SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor. You say that the submitted records support the 
medical necessity for the CGM. The Plan denied your request. The Plan says per the records, the enrollee is not 
on insulin and is not testing their blood sugars at home. 
 
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 FreeStyle Libre 2 sensor. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found coverage criteria for 
CGM require insulin use or low blood glucose sugar. The enrollee is on a medication that can cause low blood 
glucose sugar (Glipizide), but there is not mention of low blood glucose sugar. Hence coverage criteria are not 
met for CGM. This does not mean that the CGM would not help the enrollee, but it does mean that coverage 
criteria are 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 the FreeStyle Libre 2 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a FreeStyle Libre 2 sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 2, 2023, 
through June 5, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
  
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with bilateral hip pain following 
a fall at home. The workup revealed stable vital signs and negative imaging for an acute abnormality. Later in 
the course of the ED visit, she reported shortness of breath and wheezing which resolved soon afterward. The 
workup revealed a normal white blood cell count and no fever. The enrollee was diagnosed with asthma 
exacerbation but was asymptomatic on admission. Therefore, it was not expected that the enrollee would have 
required hospital care that would have likely crossed two midnights due to her stability and low complexity.  
 
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 acute inpatient hospital care provided from June 2, 2023, through June 5, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox to treat overactive bladder is 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
Botox. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
requested Botox to treat overactive bladder is medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of urinary incontinence in the setting of overactive bladder and has 
failed anti-cholinergic therapy. The Food and Drug Administration has stated that the requested drug is 
indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and 
frequency, in patients with an inadequate response to or intolerance of anticholinergic medications. The noted 
indication is not one for which the Local Coverage Determination has additional coverage requirements. The 
elements of the coverage criteria are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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 pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that you were approved for a CGM a year 
ago. You also say that you may need to take your insulin more than twice a day and sometimes as much as 4 to 
5 times a day. The Plan denied your request. The Plan says that we reviewed your medical record as well as 
Medicare's coverage guidance for this item and the medical necessity was not met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CGM and supplies. Our reviewer 
says that these items are medically necessary. Our physician reviewer found coverage criteria for CGM require 
insulin use or low blood glucose sugar. You are using insulin, 30 units two times a day. Coverage criteria for 
the CGM are 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 the CGM and supplies have been met. Therefore, we decided that the Plan has 
to pre-approve a continuous glucose monitor (CGM) and supplies.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 13, 
2023, through May 15, 2023. 
 
 
  
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with abdominal pain (burning 
epigastric symptoms) and concern that the acid reflux disease had not improved with antacids. Prior to arrival 
she had an unremarkable abdominal ultrasound. The workup revealed a computed tomography (CT) scan 
showing mild pancreatic ductal dilatation without obstruction, stable vital signs, a normal electrocardiogram 
(ECG), the endoscopy revealed no acute findings, and the enrollee was given fluids, an intravenous proton 
pump inhibitor (PPI), and planned on following up with gastrointestinal clinical as an outpatient. The enrollee 
was stable with low complexity and was not expected to require hospital care that would have likely crossed 
two midnights.  
 
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 acute inpatient hospital care provided from May 13, 2023, through May 15, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need rehabilitation so that you can gain strength 
to take care of yourself and you need assistance with your medications. The Plan denied your request. The Plan 
says the SNF services requested do not meet the requirements for approval. 
 
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 documentation does not support that you require skilled nursing services with the 
specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide care 
only in a SNF. You do not have complex wound care, new enteral feedings or other skilled nursing need that 
requires a SNF admission. Your functional level does not require the skills of a professional therapist only in a 
SNF. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter your needs do 
not require the necessary services on an inpatient basis in a SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0316x2 rendered on May 26, 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 Healthcare Common Procedure Coding System (HCPCS) code G0316 (2 units) remains not 
supported. 
 
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 G0316 is "Prolonged hospital inpatient or observation 
care evaluation and management service(s) beyond the total time for the primary service (when the primary 
service has been selected using time on the date of the primary service); each additional 15 minutes by the 
physician or qualified healthcare professional, with or without direct patient contact (list separately in addition 
to cpt codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management 
services). (do not report g0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418, 99415, 99416). (do not report g0316 for any time unit less than 15 
minutes)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation did not 
support the duration of patient contact for this encounter on this date had been 15 minutes or more beyond the 
evaluation and management service as required for G0316.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code G0316x2 rendered on May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223 
and 99233) rendered from June 16, 2023, to June 17, 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 records do not support the services 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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded 
 
CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was treated for 
tremors and weight loss. It was noted that workup for these symptoms is being completed as outpatient 
revealing polyneuropathy but was sent for electrolyte disturbances. The enrollee was noted as stable without 
new complaints without focal weakness and was hemodynamically stable. The documentation from these dates 
described an appropriate history and examination; however, the documentation did not sufficiently support a 
high level of medical decision making, nor was there documentation showing encounter notes of 75+ or 50+ 
minutes, respectively as required for CPT 99223 and 99233.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99223 and 99233) rendered from June 16, 
2023, to June 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient rehab 
provided on June 08, 2023, to June 13, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient rehab. You say that Hospital 
Inpatient Care 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 $350 
copayment for Hospital Inpatient Care. 
 
You have been asked to pay a $350 copayment for an in-network acute inpatient rehab. This item/service falls 
within the Hospital Inpatient 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 
an in-network acute inpatient rehab provided on June 08, 2023, to June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement procedures on the skin provided on May 02, 
2023. 
 
You asked the Plan to pay for debridement procedures on the skin. You say that you are requesting 
reconsideration for 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 debridement procedures 
on the skin provided on May 02, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 additional trips for routine transportation. 
 
You asked the Plan to pre-approve additional transportation.. The Plan denied your request. The Plan says you 
have exceeded your benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 72 additional trips for routine transportation.