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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 7, 2020, 
to May 8, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission should be certified due 
to the intensity of medical, nursing and ancillary services provided to this enrollee. The Plan denied your 
request. The Plan says the inpatient services were 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 enrollee received transfusion of red blood cells and had a colonoscopy. The 
enrollee was discharged in improved condition. The record does not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. Inpatient admission was 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 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 May 7, 2020, to May 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the Fire 
Department Rescue Squad on September 4, 2019. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 4, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by the 
Fire Department Rescue Squad on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-lab polysomnography for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no reason that a home or portable sleep study would not be appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  
 
 
Our physician reviewer found an attended, diagnostic PSG is considered not medically necessary, because it 
does not appear to be the appropriate test for the enrollee. The enrollee was diagnosed with OSA in 2015, and 
titrated with BiPAP, but no detail is provided as to her treatment since then.  There is no documentation of 
current sleep history.  The details of the interface problems are not provided.  The diagnosis of OSA does not 
appear to be in question. Thus, a home sleep apnea test would not be appropriate.  A split-night PSG with PAP 
titration may be needed; however, there is inadequate clinical documentation to determine that. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve in-lab polysomnography for the enrollee.
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. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
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 there is no documentation or evidence of medical issues that require monitoring by 
an inpatient rehab physician three times a week. Our reviewer found that the documentation does not support 
that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to 
rehab care. Our physician reviewer also found that the enrollee's rehab needs can be met in an alternate, less 
intense setting in a skilled nursing 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and pay more for 
abutment supported porcelain/ceramic crown (D6058) provided on February 26, 2020, by an OON provider. 
 
You asked the Plan to pay for the custom fabricated abutment or pay more for abutment supported crown. You 
say that you were told that the abutment would be covered at 50%. You also say that you were not told if there 
were any exceptions. The Plan denied your request. The Plan says custom fabricated abutment is not a covered 
benefit. The Plan also says that these services were rendered by an OON provider. 
 
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, custom fabricated abutment (D6057) is 
not among those covered under this benefit. The contract also says that abutment supported porcelain/ceramic 
crown (D6058) is a covered benefit, but you may pay more if you receive care from an out-of-network 
provider. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) 
and pay more for abutment supported porcelain/ceramic crown (D6058) provided on February 26, 2020, by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that the knee scooter is medically necessary. The 
Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that knee scooters are not covered. 
 
We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we 
decided that Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (K0553). 
 
You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that the Continuous Glucose 
Monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that for a Continuous Glucose Monitor to be covered 
the enrollee must be insulin-treated with multiple (three or more) daily injections of insulin.   
 
We looked at the file and Medicare rules. The record shows the enrollee does not use insulin three or more 
times daily. Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose 
Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous 
Glucose Monitor (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tubal ligation for sterilization for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is requesting birth control, but is 
contraindicated for oral hormone-based contraceptives due to the potential for increased weight gain, 
hypertension, and risk of thromboembolism. The Plan denied your request. The Plan says this is not a covered 
benefit for sterilization purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that sterilization procedures are not covered.  
 
It has been indicated that this request for tubal ligation is for sterilization. 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 pre-approve tubal ligation for sterilization for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a pain pump refill kit (A4220) provided June 2, 2020. 
 
You asked the Plan to pay for the pain pump refill kit. You say that the item was medically necessary. The Plan 
denied your request. The Plan says payment for this item was bundled in payment for another service. 
 
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 A4220 is not supported in the medical record. Specifically, the cost of this service is 
included in payment for the device and medication. Based on this information, we decided that Medicare rules 
for coverage of the pain pump refill kit have not been met. Therefore, we decided that the Plan does not have to 
pay for a pain pump refill kit (A4220) provided June 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT scan for lung cancer screening for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is 79 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that low dose CT scans are covered only when they 
are medically necessary for enrollles between 55 and 77 years old. 
 
The enrollee is outside the age range for this request. Based on this information, we decided that Medicare 
 
 
rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-
approve a low dose CT scan for lung cancer screening for the enrollee.
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's health is stable, and suitable for 
admission to an acute IRF. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements. 
 
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 does not require the intensity of services provided at an IRF. Our 
reviewer found that specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per 
week of rehabilitative services with regular physician evaluation. Our physician reviewer also found that the 
enrollee's care needs can be 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 22, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on April 17, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on April 17, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says needs are custodial in nature. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home biofeedback therapy. 
 
You asked the Plan to pre-approve home biofeedback therapy. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says neither Medicare nor the Plan cover home 
biofeedback therapy. 
 
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. Medicare does not cover home biofeedback therapy. Based on this 
information, we decided that Medicare rules for coverage of home biofeedback therapy have not been met.  
Therefore, we decided that the Plan does not have to pre-approve home biofeedback therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services of the Fire Department 
on May 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 18, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services of the Fire 
Department on May 18, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. 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 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. 
The enrollee had stable vital signs. The enrollee required moderate to maximal assistance with functional 
mobility including walking to 1-2 feet. The enrollee required varying assistance with activities of daily living. 
The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of 
a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are 
 
 
required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis, at a 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intrauterine device (IUD) (CPT 58300). 
 
You asked the Plan to pre-approve the IUD. You say that the body scan showed three cancer cells in the uterus. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that services with a status indicator of "N" are not 
covered by Medicare.  
 
We looked at the file, and Medicare rules. CPT 58300 has a status indicator of "N." Based on this information, 
we decided that Medicare rules for coverage of the IUD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intrauterine device (IUD) (CPT 58300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for "Tempus xT" panel gene testing provided to the enrollee on 
December 24, 2019. 
 
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 says that the "Tempus xT" panel does 
not have FDA approval, which is a requirement for coverage under Medicare's National Coverage 
Determination 90.2. The Plan also states that according to Medicare Local Coverage Article A57910 and 
A54901, a panel constitutes a single procedural service and must be billed under procedural service 81479. 
Therefore, Medicare billing criteria are not met.  
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this testing. Medicare has a 
specific code requirement for reporting this type of testing. Based on the records provided, the Medicare billing 
criteria and coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for "Tempus 
xT" panel gene testing provided to the enrollee on December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient discharge service (CPT 99239) provided on April 27, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this service 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 the services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. As the requested inpatient care was 
determined to be medically reasonable and necessary, it follows that the discharge care (CPT 99239) is also 
medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of 
the services have been met. Therefore, we decided that the Plan has to pay for the inpatient discharge service 
(CPT 99239) provided on April 27, 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.