Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services (Q0092, R0075) provided. 
 
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the referring physician was out-of-network and the provider was 
out-of-network. The services were non-emergent and there were network providers available. 
 
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 the portable x-ray services (Q0092, R0075) 
provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening lab services provided to the enrollee on February 
24, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says screening lab services are not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for screening lab services provided to the enrollee on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit services and the chronic care management 
services services provided on November 8, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit services and the chronic care management services services. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services rendered were not a covered benefit. 
 
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 the rest home visit services and the chronic care 
management services services provided on November 8, 2019 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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient'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 pneumonia and respiratory failure. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. There is not a 
reasonable expectation that this patient 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 acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammography services (CPT 77067, CPT 77063) 
provided on July 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service has already 
been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The records provided support one unit of each CPT code was 
provided on the date of service in question, which have been paid by the Plan. The additional units are not 
supported, and therefore are not payable. 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 the 
mammography services (CPT 77067, CPT 77063) provided on July 8, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for out of area hospital services provided on June 25, 2020. 
 
You asked the Plan to pay for this service. You say that you were on vacation and developed a urinary tract 
infection. This treatment was urgent and medically necessary. The Plan denied your request. The Plan says that 
out of network benefits are not covered without prior authorization. It is noted the Plans time to adjudicate this 
case expired before a decision was made. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says urgent 
or emergent services are covered by the Plan. In this case you were out of the area and developed a medical 
situation which required immediate attention. We also note the case file sent by the Plan was incomplete and 
did not provide a clear argument as to why these services should not be covered. Therefore, we decided that the 
Plan has to pay for out of area hospital services provided on June 25, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0140, D0220, D7210) provided on 
August 6, 2020. 
 
You asked the Plan to pay for the dental 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 by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The services you received were from a dentist who was not 
contracted with your Plan. Based on this information, we decided that the Plan's rules for coverage of the dental 
services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services 
(D0140, D0220, D7210) provided on August 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services from July 1, 2020, 
to July 19, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like this claim reprocessed and 
approved for payment The Plan denied your request. The Plan says since the enrollee was discharged from the 
skilled nursing facility on July 1, 2020, additional coverage is not at issue. 
 
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 looked at the file and Medicare rules. It appears from the case record that the enrollee was discharged from 
the SNF on July 1, 2020. Therefore, the additional dates of service from July 1, 2020 to July 19, 2020 cannot 
be covered. Based on this information, we decided that Medicare rules for coverage of the SNF services have 
not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) 
services from July 1, 2020, to July 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biological materials to aid in tissue regeneration 
(D3431). 
 
You asked the Plan to pre-approve the dental service. You say that you are trying to save this tooth. You say 
that your gums have many problems. You also say that this is important to you. The Plan denied your request. 
The Plan says biological materials to aid in tissue regeneration 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biological materials to aid in tissue regeneration (D3431).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient'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 planned surgery for aortic and mitral valves and for left atrial appendage closure. Medical conditions 
are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and 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. There is not a reasonable expectation that this patient 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 acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography (CPT Code 93306). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says a re-evaluation is not recommended until every three (3) to five (5) years, unless there 
has been a change in cardiac status or physical examination. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the records the patient has known coronary disease but no ischemia on stress 
echocardiography September 27, 2019, no documented anginal quality symptoms, no cardiac physical exam 
abnormalities and no ischemic electrocardiographic changes. In this circumstance, the records do not support 
the medical necessity for a repeat echocardiogram, in my opinion. Coverage criteria are not met since there are 
no documented covered indications for the procedure. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-
mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow 
Doppler echocardiography (CPT Code 93306).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a duplex scan of the extracranial arteries. 
 
You asked the Plan to pre-approve duplex scan. You say that you are appealing with records. The Plan denied 
your request. The Plan says that the denial of authorization for this service is correct, because this test is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that duplex scans may be covered under certain clinical 
indications. 
 
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 duplex scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested duplex scan. Our physician reviewer found the enrollee's 
X-Rays do show evidence of carotid atherosclerosis. In addition, she has moderate, slowly progressive aortic 
stenosis and some dyspnea with exertion. Although she does not have active neurological symptoms or carotid 
bruits, she has at least moderate aortic valvular heart disease and evidence of carotid atherosclerosis on plain 
films. Therefore, she meets the Medicare covered indication for evaluation of established or symptomatic 
coronary artery disease or cardiac valvular disease. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of duplex scan have been met. Therefore, we decided that the Plan has to pre-
approve a duplex scan of the extracranial arteries.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with advanced foot/knee ankle 
rotational unit. 
 
You asked the Plan to pre-approve these 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. Medicare rules say that a leg prosthesis is covered when specific criteria 
are met. 
 
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 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not support 
that you meet the criteria for coverage of the requested K3 ambulator status prosthesis. You do not require the 
K3 prosthesis and accessories, as it does not appear that you have vocational, therapeutic, or exercise activity 
that requires prosthesis use beyond simple locomotion or long distance ambulation. 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 a prosthetic leg with advanced foot/knee ankle rotational unit.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient's medical status does not currently require intensive physician and 
nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and 
occupational therapy, but the documentation does not support that the patient's functional status requires an 
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 acute IRF admission and services.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient'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 rhabdomyolysis and a urinary tract infection. Medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and 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. There is not a 
reasonable expectation that this patient 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 acute IRF admission and services.