Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided from 6:34 PM 
on March 22, 2020, through March 23, 2020. 

You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the enrollee's medical condition stabilized and was 
safe to transport to a plan facility. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization inpatient care. Our 
reviewer says that that inpatient care was not medically reasonable and necessary for the enrollee in this case. 
The review has determined that the treating physician did not document (in the physician notes, on a form, or in 
an order) that the patient was not stable for transfer on any dates of service. Our physician reviewer found that 
the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport to a plan 
facility for continued inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the post stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for the post stabilization inpatient care provided from 6:34 PM on March 22, 
2020, through March 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G2023, U0004) provided May 6, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 find that CPT code G2023 & U0004 is not supported in the medical record. Specifically, the claim form 
notes the specimen was obtained at a lab, however the medical records indicate the service was performed at an 
office setting. Additional documentation to correct the issue was requested by the plan and none was provided. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (G2023, U0004) provided May 6, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on June 1, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered on June 1, 2020.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an additional month of negative pressure wound therapy (NPWT) 
from September 16, 2020. 
 
You asked the Plan to pre-approve the additional month of NPWT. You say that this treatment should be 
continued as the enrollee continues to receive benefit. The Plan denied your request. The Plan says that more 
than four months of treatment with NPWT cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that NPWT may be covered for certain non-healing 
wounds when certain criteria are met. Generally, coverage ends after four months of treatment, but individual 
consideration for additional months can be given.  
 
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 additional month of NPWT. Our 
reviewer says that the documentation supports the medical necessity of an additional month of NPWT for this 
enrollee. Our physician reviewer found the patient is a 68-year-old male with right foot non-healing wound that 
was undergoing negative pressure wound therapy (NPWT) since May 2020. A request was made for extending 
this therapy. Along with wound VAC, debridement, and basic wound care, the size of the wound has reduced 
from 5 x 10 x 7 cm in May to 5.5 x 5 x 0.4 cm in Sept/2020 which would suggest benefit with the NPWT. 
Therefore, an additional month of treatment is justified and will be considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional month of NPWT have been met. Therefore, we decided that the 
Plan has to pre-approve an additional month of negative pressure wound therapy (NPWT) from September 16, 
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 hospital discharge day management services coded 
99239 provided on May 29, 2020. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or 
more for the billed date of service of May 29, 2020. Based on this information, we decided that Medicare rules 
for coverage of the hospital discharge day management services have not been met. Therefore, we decided that 
the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on 
May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the OrCam MyEye device (V2799) provided on October 31, 
2019. 
 
You asked the Plan to pay for the OrCam MyEye device. You say that the item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 does not cover these services. 
 
We looked at the file and the Plan's rules. The requested device is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the OrCam MyEye device have not been met. 
Therefore, we decided that the Plan does not have to pay for the OrCam MyEye device (V2799) provided on 
October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for biomarker testing services performed on May 19, 2020.

You asked the Plan to pay for biomarker testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says rules for payment have 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 pay for genetic testing. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that the enrollee was recently diagnosed with glioblastoma. Testing specifically related to the
enrollee's glioblastoma, for which associated therapies are known, is medically necessary and reasonable. Panel
testing, inclusive of testing that is not related to her glioblastoma or for which there are no associated therapies,
is not medically necessary or reasonable. The documentation does not support that the requested/performed
panel testing is/was 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 biomarker testing services have not been met. Therefore, we decided that the
Plan does not have to pay for biomarker testing services performed on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam you had on August 4, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $45 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
Review of the file shows that you had a Medicare-covered eye exam on August 4, 2020. You have been asked 
to pay a $45 copayment for the exam. The exam falls within the vision care 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 copayment for the eye exam you had on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the AlloSure donor-derived cell-free DNA testing provided 
on April 10, 2020. 
 
You asked the Plan to pay for the AlloSure testing. You say that this testing was medically necessary and is 
used to determine the need for an invasive renal biopsy. The Plan denied your request. The Plan says this 
testing is not covered when there is no clinical evidence of organ rejection. 
 
The Plan follows Medicare rules. Medicare rules say that the AlloSure testing may be covered for enrollees 
post-kidney transplant when there is a pretest need to assess for the probability of organ rejection. 
 
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 AlloSure testing. Our reviewer says that 
the documentation does not support that the LCD criteria have been met in this case. Our physician reviewer 
found the enrollee is a 62-year-old woman who is status post kidney transplant. The documentation does not 
support that there was a pretest need to further assess the enrollee for the probability of active renal allograft 
rejection. 
 
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 AlloSure testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the AlloSure donor-derived cell-free DNA testing provided on April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on July 7, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that 
you were not aware that these services would not be covered. You also say that you have not used your dental 
insurance. The Plan denied your request. The Plan says these services exceed the frequency limitations in your 
benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year, and panoramic x-ray (D0330) is limited to one 
procedure every three plan years. The record shows that you received a problem focused limited oral evaluation 
(D0140) on June 5, 2020 and a panoramic x-ray (D0330) on November 25, 2019, and your problem focused 
limited oral evaluation (D0140) and panoramic x-ray (D0330) benefits have been exhausted. Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab test services provided on June 20, 2019 at 
the in-network rate. 
 
You asked the Plan to pay for out of network lab tests at the in-network rate. You say that your provider did not 
tell you the cost would be this high. The Plan denied your request. The Plan says this cost share was applied 
based on the services provided and the Plan contract agreement. 
 
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 50% of 
the cost for out of network testing services. 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 pay for out of network lab test services provided on 
June 20, 2019 at the in-network rate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous lysis of epidural adhesions services coded 
62264 provided on February 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the percutaneous lysis of epidural adhesions services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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 percutaneous lysis of epidural adhesions 
services coded 62264 provided on February 28, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to approve admission to an inpatient mental health facility requested on October 
4, 2020. 
 
You asked the Plan to approve the inpatient psychiatric hospital services. The Plan denied your request. The 
Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 approve the inpatient psychiatric hospital services. 
Our reviewer says that the requested inpatient mental health facility admission is medically reasonable and 
necessary. Our physician reviewer found that it was expected this enrollee would improve in a reasonable 
period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions 
and was not showing any behavioral issues as he stated no on the suicide depression rating scale, although he 
did have suicidal ideation and auditory hallucinations on the day of admission only. It did appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as he did have dangerousness to self or others, perceptual disturbance including auditory 
and visual hallucinations on the day of admission. 
 
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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to approve admission to an inpatient mental health facility requested on October 4, 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 pre-approve a core buildup (D2950) for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requested code is not listed on the enrollee's benefit chart; therefore, it is 
not covered. 
 
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 a 
core buildup (D2950) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a second diagnostic ultrasound procedure, professional 
component, provided on May 23, 2020. 
 
You asked the Plan to pay for a second diagnostic ultrasound procedure interpretation (76870). You say that 
the records support multiple procedures were rendered on this date of service. The Plan denied your request. 
The Plan says the submitted documentation supports one unit, which was approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is only one report in the case file for procedure 76870. Based 
on this information, we decided that Medicare rules for coverage of a second diagnostic ultrasound procedure 
interpretation (76870) have not been met. Therefore, we decided that the Plan does not have to pay for a second 
diagnostic ultrasound procedure, professional component, provided on May 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on June 10, 
2020. 
 
You asked the Plan to pay for ambulance services. You say that you were called for these services. The Plan 
denied your request. The Plan says this was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says that 
the criteria for coverage of the ambulance services at issue have not been met. Our physician reviewer found 
the enrollee was transported via ambulance to the hospital from her home. She reported low back pain for one 
week after falling 3 times during the past week. She was able to walk herself to the stretcher prior to 
transportation. Vitals were stable prior to transportation. The patient did not present with symptoms that would 
meet a prudent layperson's criteria for emergency care. The documentation does not support that other means 
of transportation were contraindicated. The documentation does not support the patient's need for expertise 
services and equipment during transport to the hospital. Therefore, this request for ambulance services will be 
considered not medically necessary based on the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for ambulance services (A0425, A0427) provided on June 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided daily 
skilled services are not required. You do not require the services on an inpatient basis, in a skilled nursing 
facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case due to 
your level of pain, disability and weakness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.