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

 
We decided that the Plan has to pay for the ophthalmological services (67145, 92134, 92201, 99024) provided 
August 12, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that the services you received were for 
an emergency. The Plan denied your request. The Plan says that this was not an emergency and care could have 
been provided by plan providers. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 ophthalmological services. Our reviewer 
says that the services you received were medically necessary. Our physician reviewer found you were then a 
73-year-old man who presented to the OON provider with symptoms suggesting an eye emergency. Therefore, 
the services provided were medically reasonable and necessary for emergency 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 the ophthalmological services have been met. Therefore, we decided that the 
Plan has to pay for the ophthalmological services (67145, 92134, 92201, 99024) provided August 12, 2020, by 
an out-of-network (OON) provider.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a restoration for tooth #8. 
 
You asked the Plan to pre-approve the dental service. You say that the restoration is necessary for you to be 
able to chew food. You also say that it is necessary to save the tooth. The Plan denied your request. The Plan 
says restorations are covered once per tooth in a 2-year period. The Plan says that the frequency limit has been 
reached. 
 
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 for restorations has 
been reached. The record shows that the Plan paid for a restoration for tooth #8 on December 9, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a restoration for tooth #8.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) additional physical therapy visits (CPT Code 
G0151 x5). 
 
You asked the Plan to pre-approve the services. You say that additional visits are needed for the enrollee to 
improve. The Plan denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the services. Our physician reviewer 
found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not 
have documented skilled PT needs. The enrollee is consistently ambulating more than 100 feet with minimal 
supervision. The enrollee's care needs can be provided 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 
the services have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) 
additional physical therapy visits (CPT Code G0151 x5).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electrical stimulator supplies, 
the lumbar-sacral orthosis, the knee orthosis and suspension sleeve provided on March 26, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator (E0745), electrical stimulator supplies (A4595), the 
lumbar-sacral orthosis (L0650), the knee orthosis (L1851) and suspension sleeve (L2397). You say that the 
Plan should pay this claim. The Plan denied your request. The Plan says there is no itemized shipping invoice 
to indicate specific supplies, proof of delivery for the billed date of service, no physician order for the leads and 
the TENS device is not supported in the medical record. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the stimulator supplies or valid proof of delivery for the 
supplies provided in this case. The Delivery tickets are dated April 25, 2020 and March 12, 2020. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the neuromuscular stimulator, electrical stimulator supplies, 
the lumbar-sacral orthosis, the knee orthosis and suspension sleeve provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has a history of pulmonary 
embolisms. The Plan denied your request. The Plan says there are in-network providers who can supply the 
requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
pulmonology services 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 cytopathology services (CPT 88121) provided to the enrollee 
on July 27, 2020. 
 
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 a corrected claim is needed to be received before the claim can be reprocessed. 
 
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 88121 is "CYTOPATHOLOGY, IN SITU 
HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-
5 MOLECULAR PROBES, EACH SPECIMEN; USING COMPUTER-ASSISTED TECHNOLOGY." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found per the 
ICD-10 Coding-CM manual, diagnosis code R82.8 billed to the health plan with CPT 88121 requires a fifth 
digit be reported for the diagnosis in order to code to the greatest specificity. A code is invalid if it has not been 
coded to the fullest number of characters required for reporting the code, therefore, the service performed 
(88121) is not eligible for reimbursement based on an invalid diagnosis being billed with it. 
 
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 cytopathology services (CPT 88121) provided to the enrollee on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor System for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. 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 pre-approve a Freestyle 
Libre 2 Sensor System for the enrollee.
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 clinical records support the need for 
care in an LTACH. The Plan denied your request. The Plan says LTACH care is not medically necessary. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colorectal cancer screening; colonoscopy on individual not 
meeting criteria for high risk; once every 3 years (G0121). 
 
You asked the Plan to pre-approve a colorectal cancer screening. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that screening colonoscopies (code G0121) are covered 
under certain circumstances. 
 
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 colorectal cancer screening. Our 
reviewer says that the services are medically necessary. Our physician reviewer found in general relative to 
standard of care, and specific to member's circumstance, the USTF recommends repeat colonoscopy at 3-5 
years after detection and removal of 3-4 small adenomas without high grade dysplasia. 
 
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 colorectal cancer screening have been met. Therefore, we decided that the 
Plan has to pre-approve a colorectal cancer screening; colonoscopy on individual not meeting criteria for high 
risk; once every 3 years (G0121).  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (43239) 
provided on May 22, 2020. 
 
You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the copayment 
amount of $395.00 was applied 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 $395 
copayment for Outpatient Surgery.  
 
You have been asked to pay a $395 copayment for the esophagogastroduodenoscopy. The 
esophagogastroduodenoscopy falls within the Outpatient Surgery 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 esophagogastroduodenoscopy (43239) provided on May 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchial thermoplasty. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has severe persistent 
asthma with FEV1 of .56 liters. The published clinical trials of bronchial thermoplasty did not include patients 
of the enrollee's age or with this severe a reduction in FEV1. Furthermore, controversy remains about the 
effectiveness of bronchial thermoplasty, and most expert societies recommend that it only be done in the setting 
of a clinical trial. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bronchial thermoplasty.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 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 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 
enrollee does not meet criteria for IRF admission. 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 enrollee was admitted for foot fracture after a fall. 
Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex 
nursing or rehabilitation needs. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve durable medical equipment. You say that you would like approval for this 
equipment to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are 
in-network providers available for these services. The Plan says that you were not referred by your lung doctor. 
 
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 
durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
You asked the Plan to pre-approve IRF care. You say that a lower level of care will jeopardize the enrollee's 
health. The Plan denied your request. The Plan says the enrollee does not have complex rehab needs that can 
only be met at 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 physician reviewer found 
that the enrollee was admitted to the acute hospital for abdominal pain and constipation. His medical conditions 
are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that the provider has been paid for a lower partial 
denture, but the provider does not have a lower partial denture made for you. You say that you called the 
provider to pick up the lower denture so that you could take it to the same provider that will be doing your 
upper denture. You say that you that the provider has been working on your lower partial denture since 
February 3, 2020. You also say that you still do not have a lower partial denture. The Plan denied your request. 
The Plan says that lower partial dentures are covered once every 5 plan years. The Plan also says that the 
frequency limit has been reached. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide specific information regarding why the lower partial 
denture had not been provided. The record shows that the Plan paid for a partial lower denture on February 3, 
2020. The record shows that the Plan contacted the provider on December 22, 2020 to inquire if the partial 
lower denture had been completed and the provider?s office could not answer the question. Because the 
enrollee has not received the partial lower denture, we find that the Plan?s rules for coverage of a lower partial 
denture has not been reached. Therefore, we decided that the Plan has to pre-approve a lower partial denture 
(D5214).  
 
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.