Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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 documentation does not support that the complexity of your nursing, medical and 
rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The documentation does not support that you require at least 3 hours of therapy per day at least 5 days per 
week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that you are reasonably expected 
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 inpatient rehabilitation facility (IRF) admission and services.
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on March 4, 2022 with right cerebrovascular accident (CVA), left sided weakness and facial droop, 
and dysarthria. The complexity of her nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. There is not a reasonable expectation that the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from May 18, 2021, 
through May 19, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you do not agree with denying the 
diagnosis code as the patient was still being worked up for recurrent aspiration pneumonia. The Plan denied 
your request. The Plan says the record does not support the secondary diagnosis J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with J96.01 defined as acute respiratory failure with hypoxia. 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 hospital services. Our physician 
reviewer found that he presented with shortness of breath and wheezing but reported no shortness of breath on 
admission after initial treatment of steroids, bronchodilators, and antibiotics. Our reviewer says that the patient 
did not qualify as having acute respiratory failure, so the diagnosis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from May 18, 2021, through May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on 
October 6, 2021. 
 You asked the Plan to reimburse you for the eyeglasses. You say that you did not receive reimbursement. The 
Plan denied your request. The Plan says a check in the amount of $250 was sent to you on November 9, 2021. 
The claim processed correctly. The Plan is not required to reimburse you beyond the allowed amount of $250. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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 file shows that the Plan sent you a check in the amount of $250 
on November 9, 2021. Therefore, we decided that the Plan does not have to reimburse you an additional 
amount for the eyeglasses provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, fluorescent noninfectious agent antibody screening, 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 services rendered on October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (0242U) provided on July 19, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because 
this service was billed correctly. The Plan denied your request. The Plan says this claim was billed with an 
inappropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
  
We find that CPT code 0242U is not supported in the record. Specifically, this claim was submitted with the 
laboratory place of service code while the records do not support that the member's face-to-face service was 
rendered in a laboratory setting. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing (0242U) provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 22, 2021. 
 
You asked the Plan to pay for the testing services. You say that the denied codes are payable as billed. The Plan 
denied your request. The Plan says the testing would not impact the enrollee's treatment or management. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due. 
 
The file shows that a cardiovascular genetic testing panel was provided. We find that the testing is not 
supported in the medical record. Specifically, the records do not show that the testing was ordered by the 
enrollees treating physician to treat a specific medical problem The medical records do not show that the 
results of testing would impact clinical management. 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 lab testing services provided on May 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on June 30, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate Place of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We find that CPT code G0482 is not supported in the record. Specifically, this claim was billed with the 
laboratory place of service code while the records do not support that the member's face-to-face service was 
rendered in a laboratory. Based on this information, we decided that Medicare rules for coverage of the drug 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing services (G0482) provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 300 glucose test strips. 
 
You asked the Plan to pre-approve 300 glucose test strips. You say that you require more than the 100 allotted 
test strips for your medical condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that more than 100 test strips are covered when the 
criteria in the Medicare rules section have been met. 
 
We looked at the file and Medicare rules. In this case, the criteria for more than the 100 covered test strips have not been met. Specifically, the record does include documentation of your practitioner acknowledging the 
medical need for greater than 100 test strips. Based on this information, we decided that Medicare rules for 
coverage of 300 glucose test strips have not been met. Therefore, we decided that the Plan does not have to pre-
approve 300 glucose test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on June 14, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital services provided to the 
enrollee from July 8, 2021, through July 30, 2021, and August 15, 2021, through August 25, 2021. 
 
You asked the Plan to waive the copayments for the services. You say that the admissions were due to the 
enrollee's original COVID-19 diagnosis. The Plan denied your request. The Plan says this is the enrollee's 
contractual obligation. 
 
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 $395 
copayment per day for days 1-5 for inpatient hospital care.  
 
 
 You have been asked to pay $1975 ($395 a day for the first five days) for each inpatient stay. The services fall 
within the inpatient hospital 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 copayments for 
inpatient hospital services provided to the enrollee from July 8, 2021, through July 30, 2021, and August 15, 
2021, through August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS 
unit). 
 
You asked the Plan to pre-approve a TENS unit. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the available medical records do not support 
necessity of the device as defined by Medicare 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 pre-approve a TENS unit. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that meets the requirements 
listed in the National Coverage Determination for Medicare coverage for the requested TENS unit. As stated in 
the Medicare regulations: "TENS is not reasonable and necessary for the treatment of CLBP [chronic low back 
pain] under section 1862(a)(1)(A) of the Act." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TENS unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transcutaneous electrical nerve stimulator (TENS unit).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program provided on 
June 25, 2021. 
 
You asked the Plan to waive the copayment for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program. The Plan denied your request. 
The Plan says the claim processed with the correct copayment. 
 
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 Vision Care, Medicare covered eye exams to diagnose and treat eye conditions.  
 You have been asked to pay a $40 copayment for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program. The ophthalmological services: 
medical examination and evaluation, with initiation or continuation of diagnostic and treatment program falls 
within the Vision Care, Medicare covered eye exams to diagnose and treat eye conditions 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 ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program provided on June 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response with no transport provided to the 
enrollee on March 29, 2021. 
 
You asked the Plan to pay for ambulance response with no transport. You say that this bill should be covered 
by the Plan. The Plan denied your request. The Plan says Medicare does not cover ambulance or emergency 
response without transport. 
 
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 29, 2021. 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 ambulance response 
with no transport provided to the enrollee on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on 
August 22, 2021, during a facility stay. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says You asked the plan to pay for this service. You say that this claim should be paid. The plan 
denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for 
facility services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary.  The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under 
arrangements made with outside providers. This equipment was used during and after a surgical procedure by 
the facility. Payment for this service would have been included under the facility claim. Payment to you for this 
service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay 
for a pneumatic compression device provided to the enrollee on August 22, 2021, during a facility stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel (81206, 81210, 81235, 81272, 
81275, 81276, 81301, 81321 and 81311) provided on August 25, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because 
this testing was medically necessary. The Plan denied your request. The Plan says this claim has not been billed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel have not been met.  
 Specifically, it is not appropriate to bill this panel with individual CPT codes. Therefore, we decided that the 
Plan does not have to pay for the Tempus Gene Panel (81206, 81210, 81235, 81272, 81275, 81276, 81301, 
81321 and 81311) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493 and 64494). 
 
You asked the Plan to pre-approve facet joint injections (64493 and 64494). You say that this has been going 
on for five years, the pain has been getting progressively worse and other things have stopped working. You 
say that you just want the pain to stop, and the new injections should be more permanent. The Plan denied your 
request. The Plan says the documentation submitted does not meet the clinical criteria required to cover the 
services. 
 
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 facet joint injections (64493 and 
64494). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there are other probable pain generators, and the 
physical exam does not support facet mediated pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections (64493 and 64494) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve facet joint injections (64493 and 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that this is medically necessary for pain 
management. The Plan denied your request. The Plan says this device is not primarily medical in nature and 
will not be covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided on July 21, 2021. 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because 
this testing was medically necessary. The Plan denied your request. The Plan says this claim has not been billed 
correctly.  
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. The rules also say 
that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) 
code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel have not been met. Specifically, it is not appropriate to bill this panel with 
individual CPT codes. Additionally, this claim was billed with the laboratory Place of Service code while the 
records suggest the member's face-to-face service was not rendered in an laboratory setting. Therefore, we 
decided that the Plan does not have to pay for the Tempus Gene Panel provided on July 21, 2021.