Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup (A9270) for a CPAP machine. 
 
You asked the Plan to pre-approve the battery. You say that the battery is required due to power outages. The 
Plan denied your request. The Plan says backup batteries are 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 battery backup (A9270) for a CPAP machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear you received on June 4, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has 
been reached. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when up to $250 per year. 
 
We looked at the file and the Plan's rules. The records show that the Plan has paid the $250 benefit limit toward 
eyewear for the 2020 coverage year. Based on this information, we decided that the Plan's rules for coverage of 
the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear you 
received on June 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial hospitalization mental health services 
(H0035) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the partial hospitalization mental health services. You say that the services 
are medically necessary. The Plan denied your request. The Plan says no documentation has been provided as 
to why an in-network partial hospitalization treatment program cannot be used. 
 
Medicare rules say that plans can require enrollees to get care from 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. The plan requires pre-authorization before out-of-network partial 
hospitalization mental health treatment can be obtained. Therefore, we decided that the Plan does not have to 
pre-approve the partial hospitalization mental health services (H0035) to be provided by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace provided to the enrollee on March 31, 2020. 
 
You asked the Plan to pay for the brace. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code L0650-CG (1 Unit) 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 code. 
 
In this case, the CPT Code Manual definition of code L0650 is "Lumbar-sacral orthosis, sagittal-coronal 
control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 
vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load 
on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen 
design, prefabricated." 
 
We find that CPT code L0650 is not supported in the medical record. Specifically, the invoice shows a 
shipping date of 3/19/20 and a delivery date of 3/21/20. However, the billed date of service is 3/31/20. These 
dates do not match up, and the code cannot be verified. Based on this information, we decided that Medicare 
rules for coverage of the brace have not been met. Therefore, we decided that the Plan does not have to pay for 
a back brace provided to the enrollee on March 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve anesthesia. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct. 
 
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 anesthesia. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have a diagnosis, condition, and/or any symptoms that meet the Medicare 
criteria for coverage of monitored anesthesia care. There is no documentation indicating that it is medically 
necessary to have an anesthesiologist present during the lumbar epidural steroid injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve anesthesia for a lumbar epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on January 17, 2020 to January 
31, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient services provided on January 17, 2020 
to January 31, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunization services rendered on December 31, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 90471 is immunization administration (includes 
percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination 
vaccine/toxoid). 
 
We find that CPT code 90471 is not supported in the medical record. Specifically, the file shows that an 
influenza vaccine was administered and there is a more appropriate code for these services. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. 
 
The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.  
 
The provider submitted a claim for procedure code 90658. This code has a status indicator of I and is not valid 
for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the immunization services 
rendered on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0480 provided on November 8, 
2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation 
submitted did not include a physician order/lab requisition form or medical records stating exactly what tests 
were to be performed. The submitted Laboratory Requisition indicates that Urine Drug Screen Validity Panel 
was requested. The submitted documentation does not itemize what tests are included in this panel. Based on 
this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing coded G0480 provided on November 8, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on December 30, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the member's primary care physician did not refer these 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for genetic testing provided on December 30, 2019 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on April 29, 2019. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on April 29, 2019.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is a lack of info regarding the previous study that was approved. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
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 reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found a home PSG was ordered and approved for this patient on 12/5/2019.  It appears this test was never done 
because of scheduling difficulties.  The ordering physician is still trying to get it done. The home PSG is 
reasonable and medically necessary according to the records submitted.  It has already been approved and 
should go ahead. This is not a request for a repeat study. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a sleep study for the enrollee.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the neck (72125). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because this CT 
Scan is medically necessary. The Plan denied your request. The Plan says that an approval for the same test or 
one like it is on file and the records submitted do not show the results of this study. 
 
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. medical records were requested from the Plan and none were received. It is the 
burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and 
we must find in your favor. Therefore, we decided that the Plan has to pre-approve a CT scan of the neck 
(72125).  
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that your records show you do not require hospital-level care. 
 
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. The short-
term acute care hospital can provide for all of your present inpatient care needs and you are receiving an 
appropriate level of care in the present setting. Continued care in the short-term acute care hospital is 
appropriate until you are stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a 
sub-acute rehabilitation facility or a skilled nursing facility. Our physician reviewer found that your condition 
does not meet Medicare criteria for LTACH services. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered an investigational procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that MRS is not a covered service. 
 
The requested service is statutorily not covered. Based on this information, we decided that Medicare rules for 
coverage of the imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance spectroscopy for the enrollee.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that your functional status and 
activity tolerance requires an intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found your condition does not meet Medicare criteria for IRF 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: 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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on July 28, 2020 with septic shock with methicillin resistant staphylococcus aureus 
bacteremia due to an infected left ventricular assist device. He was treated with intravenous antibiotics. He 
suffered respiratory failure and is ventilator-dependent with a tracheotomy tube. The short-term acute care 
hospital can provide for all his present inpatient care needs and he is receiving an appropriate level of care in 
the present setting. He does not require services at the LTACH that are not available at the health care setting 
being offered by the health plan. The LTACH services are 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's records show she does not have a need for daily skilled 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.