Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it is not reasonable to 
expect that you will be safely able to participate in 3 hours of therapy a day. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that you are at a minimal assist level for bed rolling, moderate assist for sitting up, maximal assist for standing, 
and moderate assist for lying down. You do not require the intensity of services provided at an IRF.  
Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative 
services with regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical needs warrant this 
level of care to achieve a safe and sustainable discharge. The Plan denied your request. The Plan says the 
enrollee does not require extensive or complex wound care management, or daily intervention by a physician. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the acute care hospital with septic shock and hypoxic 
respiratory failure. He has been extubated and re-intubated multiple times. A tracheostomy and a PEG tube 
have been placed. The enrollee continues to be on ventilatory support. It is noted that his creatinine is 
worsening. An MRI has shown bilateral small foci of acute infarct. LTACHs are certified as acute care 
hospitals, and in general, do not provide clinical services that are materially different than those of short term 
acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file 
does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the foot x-ray (73620) provided on the April 17, 2020. 
 
You asked the Plan to pay for the foot x-ray. You say that you would like reconsideration because the record 
does not state which foot was examined. The Plan denied your request. The Plan says that this service was not 
billed with the required anatomical modifier. 
 
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 73620 is supported in the record. Specifically, the record does not indicate which foot 
was examined.  Based on this information, we decided that Medicare rules for coverage of the foot x-ray have 
been met. Therefore, we decided that the Plan has to pay for the foot x-ray (73620) provided on the April 17, 
2020.  
 
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 Comprehensive Genomic Profile (CGP) testing for the 
enrollee on May 20, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360 and NEXT-Generation) 
requires use of CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing for the enrollee on May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have chronic heal pain and receive 
injections. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tumor marker panel testing provided to the enrollee on 
January 14, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this is only indicated for metastatic non-small cell lung cancer and metastatic colorectal cancer. 
 
 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the case file does not contain documentation of advanced non-small cell lung cancer or colorectal cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for tumor marker panel testing provided to the enrollee on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen. 
 
You asked the Plan to pre-approve Oxycodone-Acetaminophen. You say that you want the enrollee treated 
with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone-
Acetaminophen.  
 
Benefits for Oxycodone-Acetaminophen may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee benefits from 
maintenance physical therapy. You say that the enrollee is likely to deteriorate without maintenance physical 
therapy. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 25, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service requires 
the billing of code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on June 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cerebral perfusion analysis using computed tomography 
(0042T) performed on June 17, 2020. 
 
You asked the Plan to pay for a cerebral perfusion analysis. You say that the procedure should be reconsidered 
for processing. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that cerebral perfusion analysis using computed 
tomography (0042T) is not a Medicare-covered service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a cerebral perfusion analysis have not been met. Therefore, we decided that the Plan does not have 
to pay for a cerebral perfusion analysis using computed tomography (0042T) performed on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical alert device. 
 
You asked the Plan to pre-approve the medical alert device. You say that you have fallen a few times while you 
were alone, and you were unable to call for help or reach the phone. You say that the medical alert device 
would improve your quality of life and safety. The Plan denied your request. The Plan says the item in dispute 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a medical alert device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cardiac device monitoring services 
provided from January 10, 2020, to April 12, 2020. 
 
You asked the Plan to waive the coinsurance for the cardiac device monitoring services. You say that you 
should not be charged for these services. The Plan denied your request. The Plan says you were appropriately 
assessed these copayments.  The Plan also says that they have reprocessed the claim for the services on 
February 10, 2020, so that date of service is not included in this decision. 
 
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 $25 
copayment for non-radiological diagnostic services.  
 
You have been asked to pay a $25 copayment for the cardiac device monitoring services. The cardiac device 
monitoring services falls within the non-radiological diagnostic services 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 coinsurance for cardiac device monitoring services provided from January 10, 2020, 
to April 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete lower dentures (D5120). 
 
You asked the Plan to pre-approve complete lower dentures. You say that the item is necessary. The Plan 
denied your request. The Plan says the covered benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one of 
D5120, D5140, D5212, and D5214 once per 60 months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of complete lower dentures have not been met. The Plan covers one of D5120, D5140, D5212, and 
D5214 once per 60 months. The record shows that you received complete lower dentures on May 8, 2019. This 
means that you are not eligible for health plan coverage of complete lower dentures at this time. Therefore, we 
decided that the Plan does not have to pre-approve complete lower dentures (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that the care required can only be provided in 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 above. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for altered mental status. Medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies and milrinone lactate injection provided 
from March 11, 2020, through March 17, 2020. 
 
You asked the Plan to pay for the infusion supplies and milrinone lactate injection. You say that the claim is on 
hold for lack of medical documentation. You say that you submitted notes for the billed services for review. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the infusion supplies and milrinone lactate injection provided 
from March 11, 2020, through March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on May 7, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with 
these charges. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $50 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services/in-network/specialist 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 a specialist office visit provided by a participating provider on May 7, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services you received on July 22, 2019. 
 
You asked the Plan to pay for the lab services. You say that you were referred to this provider. The Plan denied 
your request. The Plan says that the services are not necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. You were referred to this provider for these lab services and had a 
reasonable expectation that the services would be covered by the Plan. Under Medicare rules, this means the 
lab services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab 
services you received on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the partial upper denture, the partial lower denture, and 
the unspecified preventive dental services provided from January 21, 2020, to May 20, 2020.  
 
You asked the Plan to pay more for the dental services. You say that the plan paid less than 40% for the 
services you received. You also say that this is not what you agreed to when you signed up for the plan. The 
Plan denied your request. The Plan says 1 partial denture every 5 plan years is covered. The Plan says that the 
frequency limit has been exceeded. The Plan says that partial dentures provided out of network have a 70% 
coinsurance. The Plan also says that the unspecified preventive dental service is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 partial denture 
every 5 years has been exceeded. The record shows that the Plan paid the out of network cost share of 30% for 
the upper partial denture provided on this date of service. Additionally, the unspecified preventive dental 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay more for the partial upper denture, the partial lower denture, and the unspecified preventive dental services 
provided from January 21, 2020, to May 20, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
March 8, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to urgent care, not the ER, 
so your copayment should be less. The Plan denied your request. The Plan says you were charged this 
copayment 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 $120 
copayment for each ER visit.  
 
You have been asked to pay a $120 copayment for the ER visit. Phone records show that the facility confirmed 
you were seen in the ER and not in an urgent care setting. 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 (ER) visit you had on March 8, 2020.