Persius/hicric huggingface dataset:
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 enrollee required minimal assistance to stand up, sit down, to walk 10 feet using a 
rollator, and tub or toilet transfers. The documentation does not support that the enrollee requires the intensity 
of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services with regular physician evaluation. The enrollee's care needs can b met 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 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 non-covered chiropractic services provided from January 3, 
2020 to June 24, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the services billed are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for non-covered 
chiropractic services provided from January 3, 2020 to June 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided. 
 
You asked the Plan to pay for the air ambulance services. You say that the air transport was emergent and 
physician ordered. The Plan denied your request. The Plan says the enrollee could have been safely transferred 
by ground ambulance. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the service was not medically necessary. Our physician reviewer found the difference in time between 
ground and air do not justify the air transport. The enrollee was ambulatory, alert and oriented, and not 
 
 
hemodynamically unstable. Air transport was not indicated. Ground transport would have been appropriate. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
1, 2020, to March 10, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says the claim denied due to an issue with the Type of Bill (TOB) code recorded on the 
claim. The Plan states that if an enrollee is receiving home health services under a plan of care, the agency may 
bill certain type of service such as osteoporosis drugs, pneumonia vaccines, flu vaccines and hepatitis B 
vaccines under TOB 34X. All other services should be billed with an HHPPS episode with bill type 32X.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed due to an issue with the reported TOB code. Medicare rules for coverage of this service have not been 
met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee 
from January 1, 2020, to March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitored anesthesia (MAC) provided to the enrollee on 
January 23, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not 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 pay for these services. Our reviewer says that 
Medicare coverage criteria are not met. Our physician reviewer found the enrollee was diagnosed with type 2 
diabetes mellitus, asthma, COPD, tobacco use, and hypertension. MAC was requested for a selective nerve 
block at L4-5. There was no indication the enrollee had a symptomatic condition or procedure which required 
monitored anesthesia. Therefore, this request for MAC will be considered not 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 monitored anesthesia (MAC) provided to the enrollee on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit you had on June 3, 
2020. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that due to COVID-19 you were 
unable to go to your PCP's office.  You said that you fell down the stairs and needed x-rays and a tetanus shot. 
The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for urgent care visits.  
 
You have been asked to pay a $30 copayment for the urgent care visit. This copayment applies regardless of 
the reason for the visit. 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 urgent care visit you had on 
June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered chiropractic services provided on April 3, 2020. 
 
You asked the Plan to pay for these services. You say that this provider insisted you continue these treatments 
and told you they would be covered. The Plan denied your request. The Plan says the services billed by the 
provider are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The medical records provided show that the service 
at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for 
non-covered chiropractic services provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee 
and billed under codes 99453 and 99454. 
 
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 Medicare billing criteria were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. 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 this service. Our reviewer found the documentation submitted did not include CPT 99453 and CPT 
99454 remote monitoring of physiologic parameter(s).  The records provided do not support the services billed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services provided to the enrollee and billed under codes 99453 and 
99454.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora hearing aid check provided outof network on July 1, 2020.You asked the Plan to pay forthis service. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says you did not see a provider in the Plans required network.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and hearing aids services when theyare obtained from the Plans preferred hearing network. The provider in this case is not in the Plans hearing provider network. Therefore, we decided that the Plan does not have to pay fora hearing aid check provided out of network on July 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home physical therapy services provided on March 20, 
2020 billed with code S9131. 
 
You asked the Plan to pay for the home physical therapy as billed. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code S9131 has a status indicator of "I" in the Physician Fee Schedule, meaning that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home 
physical therapy as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
home physical therapy services provided on March 20, 2020 billed with code S9131.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora (J2704) injection, propofol, 10 mg, provided to the enrollee on December 17, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We 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 this service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the procedure report does not document that Propofol 10mg was given.  Medicare billing criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay fora (J2704) injection, propofol, 10 mg provided to the enrollee on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on June 11, 2020. 
 
You asked the Plan to pay for out of network hearing aids. You say that the Plan should cover these hearing 
aids. The Plan denied your request. The Plan says hearing aids purchased from providers other than those 
instructed by the Plan are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from designated providers. This was not a designated provider.
Therefore, we decided that the Plan does not have to pay for hearing aids purchased on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive eye exam (92014) deluxe frames (V2025) 
progressive lenses (V2781) provided. 
 
You asked the Plan to pay for the vision services. You say that this doctor has been treating your family for 
years and has knowledge of your visual problems. The Plan denied your request. The Plan says enrollee's must 
receive their vision services from an in-network provider. 
 
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 obtained from the designated in-network provider.. 
 
We looked at the file and the Plan's rules. For in-network coverage, services must be rendered by an in-network 
 
 
provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have 
not been met. Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92014) 
deluxe frames (V2025) progressive lenses (V2781) provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for anterior instrumentation (22845) provided on July 22, 2019. 
 
You asked the Plan to pay for anterior instrumentation. You say that this code is supported. The Plan denied 
your request. The Plan says the records do not contain documentation of this procedure. 
 
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 22845 is anterior instrumentation; 2 to 3 vertebral 
segments (List separately in addition to code for primary procedure). 
 
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 anterior instrumentation. Our reviewer says 
that this code is not supported in the records. Our physician reviewer found the operative report did not include 
sufficient documentation to verify service was performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anterior instrumentation have not been met. Therefore, we decided that the Plan 
does not have to pay for anterior instrumentation (22845) provided on July 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 8, 2020 and 
billed under code 81210. 
 
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 to report a Comprehensive Genomic Profile (CGP), service providers should use CPT 
code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-
CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. If CPT 
81479 is also on the claim as an unlisted unbundled item, it does not meet the Medicare prescribed use for the 
bundled code. Coverage of CGP is limited to one test per specimen and precludes the use of any other 
molecular testing on the specimen. Medicare non-coverage applies to both contracted and non-contracted 
providers and cannot be overridden by plan directed care. This is an administrative determination for coding 
and is not based on clinical criteria for medical necessity. 
 
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 claim submitted cannot be paid 
as billed due to technical error in reporting the codes. Medicare rules for coverage of this service have not been 
met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on April 
8, 2020 and billed under code 81210.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health. 
 
You asked the Plan to pre-approve inpatient mental health. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 inpatient mental health. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for 
acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others. The 
enrollee was without agitation or aggression and without perceptual disturbance including auditory or visual 
hallucinations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient mental health.
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 requires aggressive therapy and close 
physician monitoring. The Plan denied your request. The Plan says the enrollee has no intense or complex care 
needs. 
 
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 weakness and frequent falls. Her medical problems are 
stable. The complexity of her 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 pre-approve neurostimulators. 
 
You asked the Plan to pre-approve neurostimulators. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators may be 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 neurostimulators. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee does not have an 
evidence based indication for a Spinal Cord Stimulation (SCS) trial. The enrollee does not meet the coverage 
criteria. The request is considered not medically necessary or reasonable. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neurostimulators have not been met. Therefore, we decided that the Plan does 
not have to pre-approve neurostimulators.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a interlaminar/interspinous process 
stabilization/distraction device (22869). 
 
You asked the Plan to pre-approve insertion of a interlaminar/interspinous process stabilization/distraction 
device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity 
has not been established. Therefore, coverage criteria has not been met. 
 
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 insertion of a interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the spacer remains 
experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a 
interlaminar/interspinous process stabilization/distraction device (22869).