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. You say that the enrollee needs physical strengthening to regain 
his functional status. The Plan denied your request. The Plan says the enrollee is receiving adequate care in the 
LTACH. 
 
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 mitral valve replacement. Post-operatively, he was 
treated for respiratory failure, shock, atrial fibrillation and pericardial effusion. His medical problems are 
stable. The complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a 
need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation 
therapy 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on June 17, 2020. 
 
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 procedure code 99000 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99000. This code 
has a status indicator of B and is not separately payable. Therefore, we decided that the Plan does not have to 
pay for the services rendered on June 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs the LTACH services. 
The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that the enrollee appears to be stabilizing, but requires additional short term acute 
care services to help further stabilize the enrollee which can safely be completed in the current facility and are 
likely to not exceed an additional 24 days. The enrollee does not require services in the LTACH that are not 
already available at the current facility. There are no services at the LTACH that are not already available and 
covered at the current facility. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are 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 office visit provided on May 26, 2020 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 16, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 16, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine. 
 
You asked the Plan to pre-approve MRI. You say that you have ongoing pain in your neck and medication has 
not helped. The Plan denied your request. The Plan says that the denial of authorization for this service is 
correct, because you have not had 6 weeks of conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when 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 MRI. Our reviewer says that you meet 
the Medicare criteria for the requested MRI. Our physician reviewer found you have radicular pain with failed 
therapy. You will need this MRI for diagnostic purposes, and it is 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the cervical spine.  
 
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 the medical services provided on June 25, 2020 by an out-of-
network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 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 medical services provided on June 25, 2020 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need the LTACH services to 
recover. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 that there was no documentation provided necessitating admission to a LTACH. You 
are receiving appropriate care at the present acute care hospital and when considered medically stable by the 
treating team may be an appropriate candidate for care at a less intense level such as a skilled nursing facility 
(SNF). The review indicates that you do not require services at the LTACH that are not available at the acute 
care hospital where you are currently receiving care. There are no services available at the LTACH that you 
require 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 your diagnosis and condition nor are 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says that you are not using insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on November 26, 2019. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a physician order or lab requisition itemizing the specific drug classes ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or 
clear intent to order the specific lab services billed on this claim. Based on this information, we decided that 
Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have 
to pay for drug testing provided on November 26, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaker services. 
 
You asked the Plan to pre-approve homemaker services. You say that you are unable to do things for yourself 
now and need help. The Plan denied your request. The Plan says homemaker services are not covered by 
Medicare or the Plan. 
 
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 looked at the file and Medicare rules. There is no doctor certification that you need home health aide 
services and homemaker services are not covered. Based on this information, we decided that Medicare rules 
for coverage of homemaker services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve homemaker services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for IV hydration therapy and infusion, normal saline solution 
provided on March 1, 2020. 

You asked the Plan to pay for IV hydration therapy (96361) and infusion, normal saline solution (J7030). You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says the services are not 
separately payable. 

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  

We looked at the file and Medicare rules. The record shows the saline solution was incidental to other drugs 
being administered. Based on this information, we decided that Medicare rules for coverage of IV hydration 
therapy (96361) and infusion, normal saline solution (J7030) have not been met. Therefore, we decided that the 
Plan does not have to pay for IV hydration therapy and infusion, normal saline solution provided on March 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for lower intestinal endoscopic procedures, 
endoscope introduced distal to duodenum (00813) provided April 21, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that please process for payment general 
anesthesia claim with attached medical records which substantiates services performed per diagnosis denial. 
The Plan denied your request. The Plan says the diagnosis billed is not valid as a primary diagnosis. 
 
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 00813 is anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum. 
 
We find that CPT code 00813 is not supported in the medical record. Specifically, the claim was not billed with 
the appropriate primary, first-listed or principal diagnosis. The claim was billed with primary diagnosis 
D89.813-Graft-versus-host disease, unspecified. In the AMA CPT coding manual under D89.813 there is a 
code first note which states: Code First(D89.81) underlying cause, such as: complications of transplanted 
organs and tissue (T86.-) complications of blood transfusion (T80.89) CMS follows correct coding guidelines 
per the ICD-10-CM manual.  Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia 
for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum (00813) provided April 
21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on August 2, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you cannot afford 
the increase of $20 a month for this. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $354.40. The total amount you are being asked to pay is $70.88 ($354.40 x 20% = 
$70.88). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on 
August 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous image-guided lumbar decompression 
(0275T) provided January 27, 2020. 
 
You asked the Plan to pay for the percutaneous image-guided lumbar decompression. You say that the records 
provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says 
missing clinical trial information. The clinical trial number was not billed on the claim and per Medicare 
guidelines is a required item. 
 
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 0275T is Percutaneous laminotomy/laminectomy 
(interlaminar approach) for decompression of neural elements. 
 
We find that CPT code 0275T is not supported in the medical record. Specifically, the claim was missing the 
clinical trial information. The clinical trial number was not billed on the claim and is required per Medicare 
guidelines. Based on this information, we decided that Medicare rules for coverage of the percutaneous image-
guided lumbar decompression have not been met. Therefore, we decided that the Plan does not have to pay for 
the percutaneous image-guided lumbar decompression (0275T) provided January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 9, 2020 by an out of 
network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 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 medical services provided on April 9, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 11, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting. Therefore, the Place of Service (POS) code 81  indicating an independent 
laboratory setting  is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory testing provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the proton beam therapy rendered from April 21, 2020 to 
May 13, 2020. 
 
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 were 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the use of proton beam therapy is not 
routinely recommended for treatment of prostate cancer outside of a prospective clinical trial or registry. There 
is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms 
of definitive radiation therapy. The services were 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 pay for the proton beam therapy rendered from April 21, 2020 to May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 9, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on December 9, 2019.