Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism. 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that you would like reconsideration 
because you have an artificial knee and have a hard time standing from chairs. The Plan denied your request. 
The Plan says there is no documentation of severe arthritis of the hip or knee or of severe neuromuscular 
disease. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are 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 the seat lift mechanism. Our reviewer 
says that there is no indication that the managing provider has requested this seat lift due to your inability to 
stand up from a regular chair.  The documentation does not indicate that you have severe arthritis of the hip or 
knee or have a severe neuromuscular disease. Our physician reviewer found the requested seat lift is 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 the seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided. 
 
You asked the Plan to pay for the critical care 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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
support a critical care visit of 30-74 minutes was performed on the billed dates of service. The documentation 
does not include the time spent providing the service. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for the critical care services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided to the enrollee from April 13, 
2020, to April 15, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer. 
 
 
 
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 inpatient care. Our reviewer says that the 
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that by 
2:49 p.m. on April 13, 2020, the enrollee was hemodynamically stable for ambulance transfer with monitoring 
to the nearest Plan facility. COVID-19 had been ruled out with the first negative test result and the enrollee had 
been treated with IV antibiotics. There was no documentation provided necessitating post-stabilization care 
services as of 2:50p.m. on April 13, 2020. The post-stabilization care was not medically necessary or 
reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the 
enrollee was not stable for transfer on any dates of service. 
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided to the enrollee from April 13, 2020, to April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (Methylenetetrahydrofolate Reductase 
(MTHFR)) provided on February 25, 2020. 
 
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says your provider had indicated to the Plan that you were told this testing was not 
covered by Medicare prior to having it done. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. This testing is not covered by Medicare. Your physician's office reports that you 
were made aware of this prior to the test being completed. Therefore, we decided that the Plan does not have to 
pay for genetic testing (Methylenetetrahydrofolate Reductase (MTHFR)) provided on February 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that you do not believe the Plan's network 
providers can help you. The Plan denied your request. The Plan says you were previously authorized to see the 
out-of-network provider for ten (1) visits because the services needed were not available with network 
providers at the time. The Plan states that the appropriate physical therapy services are now available within the 
Plan's network or providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post 
(D3950), a surgical procedure for isolation of a tooth with a rubber dam (D3910), and drugs and medicaments 
(D9630). 
 
You asked the Plan to pre-approve the canal preparation and fitting, rubber dam, and drugs and medicaments. 
The Plan denied your request. The Plan says the dental services that you received are not listed as covered 
services. 
 
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 canal 
preparation and fitting of preformed dowel or post (D3950), a surgical procedure for isolation of a tooth with a 
rubber dam (D3910), and drugs and medicaments (D9630).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99285). 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that this visit was an 
emergency. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the "Emergency 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 an 
emergency room visit (99285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on April 3, 2020, by an out-of-network 
provider. 
 
You asked the Plan to pay for the DME. You say that the service was medically necessary. The Plan denied 
your request. The Plan says this service was done at an out-of-network provider. The Plan states this service 
was not an emergency and there are in-network providers the enrollee can go to. The Plan states there are no 
notes that say the enrollee is getting this service at an out-of-network provider because they are traveling 
outside their normal service area. 
 
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 DME provided on April 3, 2020, by an out-of-
network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oncology (prostate) testing (ConfirmMDx testing) 
provided. 
 
You asked the Plan to pay for ConfirmMDx testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that oncology testing is covered when previous 
biopsy histology does not include a prior diagnosis of prostate cancer or cellular atypia suspicious for cancer 
(but may include the presence of high-grade prostatic intraepithelial neoplasia (HGPIN). 
 
We looked at the file and Plan rules. Review of the file shows that a prior biopsy with atypical small 
acinar proliferation of the prostate, suspicious for cancer. Based on this information, we decided that Medicare 
rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Oncology (prostate) testing (ConfirmMDx testing) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Mypro Motion W (L8702, L8701). 
 
You asked the Plan to pre-approve the Mypro Motion W. You say that the enrollee has failed traditional 
rehabilitation. The Plan denied your request. The Plan says this would exceed the enrollee's needs. 
 
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 Mypro Motion W. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the beneficiary suffered from a stroke in 2015 with resulting right upper arm weakness despite 
physical therapy.  The requested device is intended to improve range of motion and does not appear to be 
indicated for strengthening a limb that has chronic weakness due to a distant stroke.  There is no documentation 
that the beneficiary has any contractures that would indicate a medical need for this device. 
 
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 Mypro Motion W have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Mypro Motion W (L8702, L8701).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of recurring cataract in lens capsule using laser 
(66821) provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the removal of recurring cataract in lens capsule using laser. You say that you 
were not aware a prior authorization needed to be filed. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 removal of recurring cataract in lens capsule 
using laser (66821) provided, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on May 
4, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that if your primary care 
provider had treated you correctly the urgent care visit would not have been necessary. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $35 
copayment for urgently needed services.  
 
You have been asked to pay a $35 copayment for urgently needed services. Urgently needed services fall 
within the urgently needed services 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 
urgently needed services provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for the denosumab injection (J0897) provided 
on April 15, 2020. 
 
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 20% of 
the cost for Medicare Part B chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay $462.18 ($2,310.88 x 20%) for the Medicare Part B drug provided. 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 adjust the coinsurance for the denosumab injection (J0897) provided on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 oncology/hematology visits at an out-of-network 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in-network providers that can provide the services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
6 oncology/hematology visits at an out-of-network provider.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
 
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 is generally medically stable with a fracture, status post-surgery shows 
no evidence of medical or nursing needs in an IRF. The enrollee's current functional status does not require IRF 
level of therapies. There is no evidence of medical issues that require monitoring by an inpatient rehab 
physician three times a week. The documentation does not support that there is a need for an intensive therapy 
program with 3 hours a day at current level of function and an interdisciplinary approach to rehab care. The 
enrollee is not expected to make a significant functional recovery in an IRF at the current pace. An IRF 
admission is not medically necessary for this enrollee, and also does not meet the CMS coverage criteria. The 
enrollee's rehab needs can be safely and effectively met in an alternate, less intense setting such as 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305, the 
immunohistochemistry or immunocytochemistry services coded 88344, and the immunohistochemistry or 
immunocytochemistry services coded 88342 provided on May 21, 2020. 
 
You asked the Plan to pay for the surgical pathology services and the immunohistochemistry or 
immunocytochemistry 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 missing required information. 
 
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 codes 88305, 88344, and 88342 are not supported in the medical record. Specifically, the 
claim is missing a required Clinical Laboratory Improvement Amendments (CLIA) number for codes 88305 
and 88344. Code 88342 is billed on the same date of service and on the same claim as code 88344. Therefore, 
code 88342 is not reimbursable. Based on this information, we decided that Medicare rules for coverage of the 
surgical pathology services and the immunohistochemistry or immunocytochemistry services have not been 
met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305, 
the immunohistochemistry or immunocytochemistry services coded 88344, and the immunohistochemistry or 
immunocytochemistry services coded 88342 provided on May 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Echocardiography provided on May 29, 
2020. 
 
You asked the Plan to waive the copayment for the Echocardiography. You say that you were told the copay 
would be $25. The Plan denied your request. The Plan says you were advised of the correct copayments of 
$110 and $25. 
 
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 $110 
copayment for diagnostic tests.  
 
You have been asked to pay a $110 copayment for the Echocardiography. The Echocardiography falls within 
the diagnostic tests 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 
Echocardiography provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the antigen therapy services (95144) and the immunotherapy 
injections (95117) rendered by the out of network (OON) provider on May 13, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 antigen therapy services (95144) and the immunotherapy injections (95117) 
rendered by the out of network (OON) provider on May 13, 2020.