Persius/hicric huggingface dataset:
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 you are appealing the denial of acute inpatient 
rehabilitation admission. The Plan denied your request. The Plan says admission was denied as not meeting 
IRF criteria, is not medically necessary, and a lower level of care might be appropriate. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 has knee osteoarthritis and is living at home with knee pain and 
trouble with ambulation. There are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different 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: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for CT scan provided on May 2, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that this was a lung scan and should have 
been covered. The Plan denied your request. The Plan says that the copayment applied is correct. 
 
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 does not say in clear and accurate 
terms when you should expect to pay $75 and when you should expect to pay $300. 
 
We looked at your contract with the Plan. We did not see where the contract says a specific copayment you 
would be asked to pay for a CT scan. The Plan contract does not clearly say when enrollees must pay $75 or 
$300 for CT scan. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the copayment for CT scan provided on May 2, 
2022.  
 
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 acute inpatient rehabilitation is medically necessary. 
The enrollee will benefit significantly from IRF and has a high tolerance to therapy. The Plan denied your 
request. The Plan says based on Medicare guidelines the inpatient rehabilitation facility 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 in the Medicare rules section. 
 
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 was admitted for surgical management of intestinal infection and 
rupture. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee 
has a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on April 6, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that it is the responsibility of the provider for the 
mistakes that were made. The Plan denied your request. The Plan says you have exceeded the limits. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The records show that you received eyeglasses on March 26, 2022. 
Your plan only covers one pair of lenses and frames every 2 years. Based on this information, we decided that 
the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pay for the eyeglasses provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (CPT code D7250) and 
dental extractions (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary. The Plan 
denied your request. The Plan says the services are not a covered benefit under the Plan. The Plan states your 
benefits say you are not enrolled in an optional supplemental benefit package beyond that 
which is required by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve removal of residual 
tooth roots (CPT code D7250) and dental extractions (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that going to the in-network provider 
would present a hardship due to driving time and distance. You say the out-of-network is closer. The Plan 
denied your request. The Plan says the provider is out-of-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 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 physical therapy services. We found no exception that would require the Plan to 
pre-approve the physical therapy services. The record shows there are in-network providers within the travel 
guidelines. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be 
provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
drug testing. We found no exception that would require the Plan to pay for the drug testing. The records 
provided for review do not show that the drug testing was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on May 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits and psychotherapy provided from January 
14, 2021, to December 16, 2021. 
 
You asked the Plan to pay for the physician services. You say that you needed these services for your mental 
health. You also say that with your insurance it is difficult to find providers. The Plan denied your request. The 
Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made to a 
provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visits and psychotherapy provided from January 14, 2021, to December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided by a chiropractor on 
January 19, 2022, and January 21, 2022. 
 
You asked the Plan to pay for PT services. You say that you need manual physical therapy for the pain in your 
neck. The Plan denied your request. The Plan says these services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical therapy (PT) services provided by a chiropractor on January 19, 
2022, and January 21, 2022.
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 you are appealing the denial of acute inpatient 
rehabilitation admission. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information we have about your condition you do 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 in the Medicare rules section. 
 
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 you were admitted for respiratory failure and rib fractures after a fall. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for physical 
or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on February 3, 2022. 
 
You asked the Plan to pay for the services provided. You say that two procedures were performed by two 
separate physicians. The Plan denied your request. The Plan says the procedure is not paid separately. 
 
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 01992 is anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional); prone position. 
 
 We find that CPT code 01992 has a status indicator of J on the Physician Fee Schedule. This means that the 
procedure code is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services provided on February 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service April 21, 
2022. You asked the Plan to pay for the services provided. You say that the relationship between procedures allows 
for the use of a modifier. The Plan denied your request. The Plan says the service cannot be separately paid. 
 
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, we have confirmed that code 36556 is a column II code to column I code 93503. The records in the 
case file do not show that the code at issue has not been billed with an appropriate modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 36556 billed for date of service April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two periodontal scalings and root planings (D4341 x2). 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says the 
requested procedure is not covered, and there is no enhanced dental coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 two 
periodontal scalings and root planings (D4341 x2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on March 12, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that your oxygen levels had returned to normal 
when the paramedics arrived to your house. You also say that you felt you no longer needed to go to the 
hospital. The Plan denied your request. The Plan says since no transport was provided, there is no payable 
service. 
 
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 March 12, 2022. 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 response and treatment, no 
transport, (A0998) provided on March 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services (A0432) provided on October 
28, 2021. 
 
You asked the Plan to pay for paramedic intercept. You say that these services were necessary. The Plan denied 
your request. The Plan says paramedic intercept services are excluded from Medicare coverage in this case.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept services (A0432) provided on October 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health PT visits and home health OT 
visits. 
 
You asked the Plan to pre-approve the home health services. You say that you have no valid means of 
transportation, you cannot walk more than a few steps, you can hardly raise your arms. The Plan denied your request. The Plan says you are unable to fully participate in the PT and OT and you have achieved maximum 
benefit from the therapy and further therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found there is no documentation that the additional home health physical therapy (PT) visits and 
home health occupational therapy (OT) visits at issue in this case meet Medicare criteria for medically 
reasonable and necessary. The provided records document that you are walking up to six feet with moderate 
assistance and are maximum assist dependent for transfers and activities of daily living. Provided records 
report you are unable to fully participate with PT and OT and you have reached your maximum rehabilitation 
potential with the therapy services already approved by the Plan. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health PT visits and home health OT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99230) provided on March 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says authorization was not obtained before the service was rendered to the 
enrollee. 
 
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 had network providers 
available who could have provided 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 office visit (99230) provided on March 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne testing provided on February 1, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says that the testing is not a covered 
benefit. 
 
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. 
 
We looked at the file and the rules. In this case, the testing was provided to a patient with a solid tumor. The 
FDA approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the FoundationOne testing provided on February 1, 2022.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on April 6, 
2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was requested by the enrollee's 
physician. The Plan denied your request. The Plan says the procedure codes billed are not correct for the 
services. 
 
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 panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenomics panel testing provided on April 6, 2022.