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

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan 
denied your request. The Plan says the stay is not necessary. The Plan states they approved observation care. 
 
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 pre-approve 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 there was insufficient evidence of a complicated urinary tract infection 
(UTI) such as pyelonephritis. White blood cell (WBC) count was normal. Vitals were stable. This clinical 
presentation warrants observation care to insure improvement with treatment initiated in the emergency 
department (ED), however, the patient was stable enough to where inpatient services were not warranted and 
would not likely have required more than two midnights of hospital care 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 22, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not include a valid physician order/lab requisition (signed by 
the ordering physician); therefore, the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say lab services must be preceded by a valid physician 
order.  
 
There is no evidence in the case file of a valid physician order for these tests. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory services provided to the enrollee on April 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from December 31, 2019, through January 1, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that you should not be financially liable for the copayment amount since the hospital failed to ask your permission to be admitted for one day.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on December 31, 2019, and discharged on January 1, 2020. You were asked to pay a $370 copayment for December 31, 2019, days 1 of your inpatient hospital care. You were discharged on January 1, 2020, and there was no copayment charge for the day of discharge. Per your contract there is a $370 copayment per day required for days 1-5. 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 forinpatient hospital care provided from December 31, 2019, through January 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen supplies (E0442) provided from May 22, 2020 to 
June 5, 2020. 
 
You asked the Plan to pay for the oxygen supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the maximum allowable units were exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code E0442 is 1. You billed 54 units, 61 units, 63 units, and 62 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen 
supplies (E0442) provided from May 22, 2020 to June 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on November 5, 2019, 
through November 22, 2019. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration 
because these services were medically necessary. The Plan denied your request. The Plan says physical therapy 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our reviewer 
says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the  specialized skill, knowledge and judgment of a 
 
 
qualified therapist was not required to establish, design and/or deliver a program to maintain the member's 
current condition or to prevent or slow further deterioration. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on November 5, 2019, through November 22, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) provided 
on October 31, 2019. 
 
You asked the Plan to pay for the eye refraction. You say that the claim should be paid. The Plan denied your 
request. The Plan says the refraction is not covered by Medicare as it is inclusive with the eye exam visit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
 
 
The Plan has issued a payment on August 31, 2020, of $103.88 for the eye exam visit due to services were 
rendered during transition of care. However, the refraction is not covered by Medicare as it is inclusive with the 
eye exam visit. Therefore, we decided that the Plan does not have to pay for determination of refractive state 
(CPT Code 92015) provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test with CPT code 83036 provided on 
February 27, 2020. 
 
You asked the Plan to pay for CPT code 83036. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, CPT code 83036, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the laboratory test with CPT code 83036 provided on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PCR amplification Molecular UTI test provided on 
March 18, 2020. 
 
You asked the Plan to pay for the UTI test. The Plan denied your request. The Plan says this is not medically 
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 pay for the UTI test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that PCR amplification techniques raise considerable concerns regarding contamination from one 
specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results 
may also be challenging. Amplification of organisms representing latent infection or colonization cannot be 
distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of 
nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, 
specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large 
groups of patients for many of the microorganisms. 
 
 
 
 
 
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 UTI test have not been met. Therefore, we decided that the Plan does not 
have to pay for the PCR amplification Molecular UTI test provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided on April 20, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that you would like reconsideration because this equipment is medically necessary.The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.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 ifthe Plan was correct in denying the request to pay for the lumbar-sacral orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence ona physical exam that the member obtains reduced pain with restricting mobility of the trunk. There is no evidence that he has had an injury to the spine or related soft tissues that requires healing. There is no evidence that he has weak spinal muscles ora deformed spine on a physical exam that requires this brace. There is no evidence that the treating physician has recommended this brace as part of the treatment plan in the office notes.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 lumbar sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided on April 20, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI, pelvis; without contrast material(s), followed by contrast 
material(s) and further sequences (CPT Code 72197), MRI, pelvis; without contrast material(s) (CPT Code 
72195) and MRI, pelvis; with contrast material(s) (CPT Code 72196). 
 
You asked the Plan to pre-approve the MRI's. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI's. Our physician reviewer 
found while not a typical indication for MRI, this procedure has the potential to better characterize a 
debilitating problem. Our physician reviews feels the study, after extensive workup, and failed rehab, is 
indicated and the denial should be overturned. 
 
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 MRI's have been met. Therefore, we decided that the Plan has to pre-
approve CPT Code 72197, CPT Code 72195 and CPT Code 72196.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation does not indicate that the enrollee requires frequent and immediate 
changes in body position. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary 
bed. The documentation does not support a need for an immediate change in body position or frequent need for 
 
 
change in position or special attachments that cannot be fixed on an ordinary bed. The physician documentation 
does not indicate the specific angle needed for elevation for COPD or other problems. The request for a semi-
electric hospital bed 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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee 
on March 17, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the case file does not contain clinical records supporting that the molecular genetic screening testing 
provided on 3/17/20 was medically reasonable and necessary for this enrollee. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for molecular genetic screening testing provided to the enrollee on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this 
coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% 
coinsurance for Medicare prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $547.68. The total amount you are being asked to pay is $109.54 ($547.68 x 20% = $109.54). An 
injection falls within the Medicare prescription drugs 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 coinsurance for an injection provided by a participating provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
24, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received ambulance services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $250 
copayment for Ambulance services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance 
services on May 24, 2020. You have been asked to pay a $250 copayment for the ambulance services. The 
ambulance services fall within the Ambulance 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 the ambulance services provided on May 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental. More research is needed to show both safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
March 9, 2020 to May 7, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the date span is incorrect on the claim. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
 
 
 
 
 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, it appears 
that the date span is incorrect on the claim. The approved authorization dates were March 21, 2020 to May 19, 
2020. The billed dates of service were from March 9, 2020 to May 7, 2020. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from March 9, 2020 to May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a powered pressure-reducing air mattress. 
 
You asked the Plan to pay for the mattress. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation does not show that the member 
meet Medicare coverage criteria. 
 
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 the mattress. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not indicate multiple stage II pressure ulcers located on the trunk or 
pelvis which have failed to improve over the past month. The member does not have large or multiple stage III 
or IV pressure ulcer(s) on the trunk or pelvis and has not had a myocutaneous flap or skin graft for a pressure 
ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately 
prior to discharge from a hospital or nursing facility within the past 30 days. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pay for a powered pressure-reducing air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral occlusal appliance provided on March 4, 2020. 
 
You asked the Plan to pay for the oral appliance. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says oral occlusal appliances used to treat TMJ 
disorders are considered to be dental services and are non-covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Oral occlusal appliances are not covered to treat TMJ. Therefore, we decided that the Plan does not have to pay 
for oral occlusal appliance provided on March 4, 2020.