Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5261) purchased on March 18, 2020. 
 
You asked the Plan to pay for hearing aids. You say that you were not aware that your prior authorization for 
hearing aids was time limited and would expire. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 obtained from a provider.  
 
We looked at the case file and the Plan's rules. The Plan has confirmed that the provider in this case is not a 
provider. Based on this information, we decided that the Plan's rules for coverage of hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261) 
purchased on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 7, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you didn't have vitals taken, you 
weren't examined, and you weren't given medication. You say that you don?t see this being charged as a 
doctor's visit. The Plan denied your request. The Plan says the copayment applied 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 $40 
copayment for visits to specialists.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor?s office visits" 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 office visit provided on May 7, 2020.
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 stay is 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 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have been receiving 
skilled nursing services since their discharge on November 28, 2020, from acute care stay for stroke like 
symptoms. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve (CPT Code 22845), (22846), (22552), (22551) and 
(22853). 
 
You asked the Plan to pre-approve the services. You say that you are experiencing severe pain that limits day 
to day activity. The Plan denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the medical records do not show that you have high pain scores. There 
is very low levels of neck and arm pain documented. There is no severe neuro deficit of spinal instability 
documented. Criteria for surgery 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 the services have not been met.  
Therefore, we decided that the Plan does not have to pre-approve (CPT Code 22845), (22846), (22552), 
(22551) and (22853).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve hydrogen breath test in the evaluation of small intestinal bacterial 
overgrowth. 
 
You asked the Plan to pre-approve hydrogen breath test. You say that this test is medically necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pre-approve hydrogen breath test. Our reviewer says that the requested 
services are considered medically reasonable and necessary in this case. Our physician reviewer found it is 
medically appropriate to include hydrogen breath test in the evaluation of small intestinal bacterial overgrowth. 
The ACG guidelines and North American Consensus both support the use of and advocate the importance of 
hydrogen breath test for the diagnosis of small bowel bacterial overgrowth.  Medical necessity is established.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hydrogen breath test have been met. Therefore, we decided that the Plan has to 
pre-approve hydrogen breath test in the evaluation of small intestinal bacterial overgrowth.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 7, 
2020, to July 6, 2020. 
 
You asked the Plan to pay for the SNF care. You say that it is felt that Medicare payment can be made for these 
services. The Plan denied your request. The Plan says the member did not have skilled events during the 
appealed period. This was correctly denied as custodial care. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary.  
 
 
Our physician reviewer found from a nursing perspective, the beneficiary received oral medications and 
insulin. The beneficiary had stable vital signs. Her skin was intact. Her sugars were variable. Regarding 
rehabilitation services, the beneficiary did not require any daily skilled PT or OT intervention for the dates in 
question.  
  
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from June 7, 2020, to July 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan has to pay for the home health services billed for dates of service June 8, 2020, 
through June 17, 2020. 
 
You asked the Plan to pay for the home health services. You say that this was billed correctly and should be 
paid. The Plan denied your request. The Plan says that there was missing information on this claim, and it was 
denied correctly. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Based on review of the entirety of the file, we find that there is insufficient 
documentation to support the Plan's denial rationale in this case. It is not clear from the file whether the denied 
payment at issue is for a Request for Anticipated Payment (RAP) or the final claim of the episode of care. The 
remittance advice only has five line items compared to the 22 line items on the copy of the final claim provided 
by the appellant. The Plan did not provide a copy of the actual claim received which was denied on July 22, 
2020. Without a copy of this so that the Type of Bill can be checked, we cannot confirm whether the denial 
rationale of a missing item for the location of care is valid. A RAP, Type of Bill 0322, does not require a Q-
code to report location of services. As such, we find that the denial of payment is not supported based on the 
available information provided by the Plan. Therefore, we decided that the Plan has to pay for the home health 
services billed for dates of service June 8, 2020, through June 17, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for immunohistochemistry or immunocytochemistry (88341) provided on 
August 4, 2020. 
 
You asked the Plan to pay for immunohistochemistry or immunocytochemistry. You say that this was billed 
correctly. The Plan denied your request. The Plan says that this is not supported because it was billed with 
88344. 
 
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 immunohistochemistry or 
immunocytochemistry. Our reviewer says that the billing of this code is supported by the medical records. Our 
physician reviewer found CPT code 88342 is a primary procedure code, and includes "per specimen" in the 
description. CPT code 88341 is an add-on code, and would be used for each additional single probe stain 
procedure per specimen. The documentation supports CPT code 88341. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of immunohistochemistry or immunocytochemistry have been met. Therefore, we 
decided that the Plan has to pay for immunohistochemistry or immunocytochemistry (88341) provided on 
August 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: 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 stay is 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 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for non-surgical management of a hip fracture and for treatment of atrial fibrillation. Medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
 
 
 
 
 
 
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 dental services provided to you by an out-of-network 
provider on September 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. 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 the dental services provided to you by an out-of-network provider on 
September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be more stable overall, however, they require additional short 
term acute care services which can safely be completed in the current setting. The patient does not require 
services at the LTACH that are not already available at the current facility. There are no services at the LTACH 
that the patient requires that are not already available and covered at the current facility. Therefore, this request 
for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care 
may be considered soon when treatment has completed and it is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has 
completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard testing. 
 
You asked the Plan to pre-approve Cologuard testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard is only covered for enrollees that are 
asymptomatic. 
 
We looked at the file and Medicare rules. Review of the file shows that you have Irritable Bowel Syndrome, 
loose stools and abnormal liver tests. This shows that you are not asymptomatic. Based on this information, we 
decided that Medicare rules for coverage of Cologuard testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Cologuard testing.
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 the service is medically necessary. The Plan denied 
your request. The Plan says the member does not meet the criteria for admission to an Inpatient Rehabilitation 
Facility. 
 
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 that there are no complex nursing or rehabilitation needs and the patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation 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. Specifically, the service is not medically necessary. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) 
admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), intraoral - periapical 
first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and pulp 
vitality tests (D0460). 
 
You asked the Plan to pre-approve a limited oral evaluation, intraoral - periapical first radiographic image, 
intraoral - periapical each additional radiographic image, and pulp vitality tests. You say that the services are 
necessary. The Plan denied your request. The Plan says the requested services are 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 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 
limited oral evaluation (D0140), intraoral - periapical first radiographic image (D0220), intraoral - periapical 
each additional radiographic image (D0230), and pulp vitality tests (D0460).