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 an intensive physical and occupational therapy 
program is needed to address functional mobility. The Plan denied your request. The Plan says the enrollee 
does not have complex medical or rehab needs requiring physician supervision or an interdisciplinary team. 
 
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 is generally medically stable after a below knee amputation, with no recent neurological or 
orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient 
rehab physician three times per week, or a need for acute rehab nursing care. While the enrollee may benefit 
from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy 
program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to 
rehabilitation care. Therefore, an admission to an IRF is not medically necessary based on lack of medical 
complexity and lack of progress. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services rendered from 
December 22, 2018 to January 20, 2019. 
 
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 were not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on 
December 22, 2018 after a hospitalization due to inadequate social support. She was noted to be at her previous 
level of functioning. She did not have any daily complex wound care or parenteral medications. She had been 
medically stable. The enrollee required custodial care. She had no skilled nursing or skilled therapy needs and 
did not require the services on a daily basis. As a practical matter, the enrollee did not require the necessary 
services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) services rendered from December 22, 2018 to January 
20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a magnetic resonance imaging (MRI), 
laboratory services, and specialist visits provided from January 10, 2020 to February 19, 2020. 
 
You asked the Plan to waive the copayments for an MRI, laboratory services, and specialist visits. You say that 
you have met your out-of-pocket maximum. The Plan denied your request. The Plan says these services 
processed 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 pay a 
$40 copayment for each specialist visit, a $20 copayment for laboratory tests, and $270 for outpatient 
diagnostic tests including MRIs. Your 2020 out-of-pocket maximum for 2020 is $6,700. 
 
The record shows that you had not met the 2020 out-of-pocket maximum at the time these services were 
rendered and processed. You have been asked to pay $270 for an MRI, $20 or less for each date of service of 
laboratory services, and $40 or less for each specialist 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 copayments for a magnetic resonance imaging 
(MRI), laboratory services, and specialist visits provided from January 10, 2020 to February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine drug testing rendered on December 13, 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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the urine drug testing rendered on 
December 13, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GI-Map testing provided on September 17, 2019. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the clinical 
benefit of this testing has not been demonstrated by large randomized studies. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing 
why the lab services provided were medically necessary. 
 
We looked at the file and the rules. We find that the testing is not supported in the medical records. In this case, 
there were insufficient records provided to show the results of this testing would be used to determine a 
specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the 
time of service. This testing is not covered for screening purposes. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the GI-Map testing provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 64495) provided on February 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 64495 is "Injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 
procedure)". 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use 
of CPT code 64495 is not supported by the records provided. Our coding reviewer found that the procedure 
report documents that 3 medial branch nerves were blocked, therefore only 2 facet joints would be reported. 
Therefore, 64495-50 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 64495) provided on February 17, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on February 3, 2020. 
 
You asked the Plan to pay for genetic tests. You say that the enrollee met the criteria for this testing. The Plan 
denied your request. The Plan says that the denial of payment for these services is correct, because prior 
authorization was not obtained, and these tests are not covered by Medicare. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. The Plan contract does not clearly state that prior authorization is required for 
genetic testing performed by an independent laboratory. These tests were not explicitly excluded from 
Medicare coverage for date of service February 3, 2020. Without this information, we cannot determine 
whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to 
deny payment for these tests is correct or justified by Medicare rules. Therefore, we decided that the Plan has to 
pay for genetic testing provided on February 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided from 
November 22, 2019 to February 11, 2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that it is essential that the enrollee 
be seen by the attending physician to aid in proper coordination of enrollee care. You also say that because the 
provider is not a facility paid employee, you should not be held liable for obtaining an authorization. The Plan 
denied your request. The Plan says the enrollee is required to obtain covered services from Plan providers. The 
Plan also says that the Plan did not authorize routine follow up care to the enrollee at this facility. 
 
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 
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 subsequent nursing facility care provided from 
November 22, 2019 to February 11, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement (D6101) and occlusal adjustment (D9951) 
provided on March 3, 2020. 
 
You asked the Plan to pay for debridement (D6101) and occlusal adjustment (D9951). You say that this is 
recommended treatment. You say that the claim should be considered for maximum benefits. The Plan denied 
your request. The Plan says the services are not covered benefits. 
 
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 pay for 
debridement (D6101) and occlusal adjustment (D9951) provided on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series x-ray provided on February 28, 
2020. 
 
You asked the Plan to pay for the intraoral complete series x-ray. You say that you are appealing the denied x-
ray. The Plan denied your request. The Plan says the x-rays are only covered once every 3 years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one complete series x-ray every 36 months. The Plan paid for an intraoral complete series x-ray provided on 
February 6, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for 
the intraoral complete series x-ray provided on February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 31, 
2019 through April 1, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 31, 2019 through April 1, 
2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept service provided to the enrollee on 
March 5, 2020. 
 
You asked the Plan to pay for the paramedic intercept service. You say that the assisted living facility called 
the ambulance and you had no control over what ambulance company was sent because it was an emergency. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for the paramedic intercept service provided to the enrollee on 
March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical van transport provided on March 26, 2020. 
 
You asked the Plan to pay for the medical van transport. You say that this was the only way to get home 
because your sister could not bring you back home and you did not want to stay due to COVID 
concerns. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical van transport have not been met. The services were provided by a medical van. This 
was a non-emergency transport; not transported to the nearest facility or a higher level of care. Transport was 
for your convenience and not necessary diagnostic or medical purposes. Medical van transport is not covered 
under Original Medicare guidelines. You self-paid for transport and were aware of non-coverage. Therefore, 
we decided that the Plan does not have to pay for the medical van transport provided on March 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported prosthesis repair (D6090) provided on 
January 6, 2020. 
 
You asked the Plan to pay for the implant supported prosthesis repair (D6090). You say that the approved 
services would have cost $2,000 more. You say that the services were necessary and should be paid. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for the 
implant supported prosthesis repair (D6090) provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on January 14, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. 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 drug testing services 
(HCPCS G0483) provided to the enrollee on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acrylic socket and an advanced foot and ankle 
(L5981, L5968, L5629, and L5940). 
 
You asked the Plan to pre-approve an acrylic socket and an advanced foot and ankle. You say that the items 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 when an initial below knee prosthesis (L5500) or a 
preparatory below knee prosthesis (L5510, L5520,L5530, L5540) is provided, prosthetic substitutions and/or 
additions of procedures and components are covered in accordance with the functional level assessment except 
for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not 
reasonable and 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 an acrylic socket and an advanced foot 
and ankle. Our reviewer says that the items are not medically necessary. Our physician reviewer found based 
on the medical records provided there is no documentation that the enrollee meets the coverage criteria for the 
preparatory prosthesis with an acrylic socket and an advanced foot and ankle. Based on the records provided 
and the enrollee's condition a preparatory prosthesis with K-2 level foot and ankle appears more appropriate in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an acrylic socket and an advanced foot and ankle have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an acrylic socket and an advanced foot and ankle 
(L5981, L5968, L5629, and L5940).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker (E0143) and seat attachment (E0156). 
 
You asked the Plan to pre-approve a walker and seat attachment. You say that the items 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 a standard walker (E0130, E0135, E0141, E0143) and 
related accessories are covered if specific criteria is 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 a walker and seat attachment. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found the records do not 
indicate this enrollee suffers from significantly impaired balance or endurance, and/or that a standard cane 
could not address mobility limitations. As such, this request is not in line with criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a walker and seat attachment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a walker (E0143) and seat attachment (E0156).