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 enrollee is functioning at a home care level with ambulation and transfers. The 
enrollee does not have intensive or complex rehabilitation needs. 
 
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 waive the copayment for laboratory services provided on March 11, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that this should be covered since it was 
on the same day you had an office visit. The Plan denied your request. The Plan says 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 clearly says that you must pay $10 
copayment per day for other Medicare-covered laboratory tests that are not FIT tests.  
 
 
 
 You have been asked to pay $8.07 which is less than the standard $10 copayment for lab services. Lab services 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on March 11, 2022.
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 criteria for IRF care have been met. You say that 
the documentation provided supports the need for IRF care. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the services needed can safely be provided in 
other settings. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for Fournier's gangrene, sepsis, and a colostomy. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 1, 2020, billed 
with codes 81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81275, 81270, 81235, 81210, 81201, 
81314, 81311, 81310, 81293, 81276, 81272, 81121, and 81120. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed 
appropriately per Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 1, 2020, billed with codes 81406, 81405, 81404, 81403, 81402, 81401, 81400, 81321, 81275, 
81270, 81235, 81210, 81201, 81314, 81311, 81310, 81293, 81276, 81272, 81121, and 81120.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tooth-root and mandibular implant procedure (CPT 
code 21299). 
 
You asked the Plan to pre-approve the dental services. You say that you are already suffering from 
malnutrition, stomach pain and gut problems. The Plan denied your request. The Plan says your request for this 
dental implant is not a covered benefit under Medicare. 
 
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. The service is not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve the tooth-root 
and mandibular implant procedure (CPT code 21299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have a bunion on both of your feet and can 
hardly walk. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 6, 2021, billed 
with codes 81225, 81226, 81230, 81291, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 6, 2021, billed with codes 81225, 81226, 81230, 81291, and 81335.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy services (CPT code 
G0151 x5) and the home health skilled nursing services (CPT code G0299 x5). 
 
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not 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 the documentation does not support that the enrollee requires additional skilled nursing services 
or skilled rehabilitation services to provide treatment that is medically necessary. The enrollee does not require 
additional skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in 
order to improve the enrollees condition, perform a maintenance program to maintain the enrollee's condition 
and/or prevent deterioration. The enrollee has been medically stable without any recurrent exacerbations of 
chronic medical problems or hospitalizations. The requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health physical therapy services (CPT code G0151 x5) and the home 
health skilled nursing services (CPT code G0299 x5).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight portable motorize power wheelchair. 
 
You asked the Plan to pre-approve a lightweight portable motorize power wheelchair. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 
 The documentation does not include a therapist evaluation with a recent home assessment of suitability for the 
enrollee. The documentation does not support that the enrollee can safely operate the PMD being requested. 
This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight portable motorize power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dermatology services provided to the 
enrollee on April 20, 2021. 
 
You asked the Plan to waive the copayment for the services. You say that this was medically necessary. The 
Plan denied your request. The Plan says the claim was processed appropriately. 
 
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 $30 
copayment for specialist office visits.  
 
You have been asked to pay a $30 copayment for the services. the services falls within the specialist office 
visits benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for dermatology services provided 
to the enrollee on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided on March 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for a spinal cord stimulator (paddle lead insertion via 
laminectomy). 
 
You asked the Plan to pre-approve the spinal cord stimulator. You say that the requested procedure is 
medically necessary. The Plan denied your request. The Plan says, based on the clinical information received, 
the request 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 pre-approve the spinal cord stimulator. Our reviewer 
says that the removal of a 2-lead spinal cord stimulator, with performance of a T9-10 laminectomy with 
placement of a paddle lead is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has chronic pain due to lumbar spinal stenosis with radiculopathy. A lumbar fusion 
was performed in 2000, and cages were placed in 2003. Exercise, medication, and injections have provided 
minimal relief. On June 29, 2022, it is documented that the provider is recommending removal of the 2-lead 
spinal cord stimulator and performing a T9-10 laminectomy with a paddle lead for better coverage.  
 The enrollees current diagnoses include lumbar stenosis with neurogenic claudication, chronic pain syndrome, 
lumbar degenerative disc disease, lumbar post-laminectomy syndrome, and other spondylosis with 
radiculopathy. There is insufficient documentation to support that the procedure is reasonably expected to 
result in significant improvement of the enrollees condition. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve for a spinal cord stimulator (paddle lead insertion via laminectomy).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September 
10, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says the copayment applied was 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 clearly says that you must pay a $50 
copayment for in or out of network urgently needed services.  
 
You have been asked to pay a $50 copayment for an urgent care visit. An urgent care visit falls 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 an urgent 
care visit provided on September 10, 2021.  
 Your complaint about the dissatisfaction with the provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colorectal cancer screening (G0105) provided on February 
8, 2022. 
 
You asked the Plan to pay for a colorectal cancer screening. You say that this service was necessary and was 
billed appropriately. The Plan denied your request. The Plan says a family history diagnosis code was 
submitted as the principal diagnosis for this claim, which is not correct by Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that the reason for encounter (such as screening or counseling) should be sequenced before a family 
history code when reporting diagnoses on a claim. 
 
We find that this claim was not billed according to Medicare regulations. Specifically, a family history code 
was billed as a principal diagnosis when it must be sequenced after a reason for encounter. Based on this 
information, we decided that Medicare rules for coverage of a colorectal cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for a colorectal cancer screening (G0105) provided on 
February 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovana. 
 
You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Brovana. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 Brovana. Our reviewer says that 
Brovana is not reasonable and necessary. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one 
alternative. Our reviewer also found that the elements of the coverage criteria are not satisfied, and the 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Brovana.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for shoulder orthosis on April 12, 2022. 
 
You asked the Plan to waive the coinsurance for shoulder orthosis. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged 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 clearly says that you must pay a 20% 
coinsurance for Medicare-covered prosthetic devices, supplies related to prosthetic devices, and orthotics 
Prosthetic devices and related supplies. Devices (other than dental) that replace all or part of a body part or 
function. These include but are not limited to: colostomy bags and supplies directly related to colostomy care, 
pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after 
a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or replacement of 
prosthetic devices. Also includes some coverage following cataract removal or cataract surgery  see Vision 
Care later in this section for more detail. The provider billed in the amount of $165 and the allowed amount is 
$137.17. $137.17 x 20% = $27.43. Therefore, results in the total cost-sharing amount of $27.43. 
  
You have been asked to pay a 20% coinsurance for shoulder orthosis. Shoulder orthosis falls within the 
Prosthetic devices and related supplies 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 shoulder orthosis on April 12, 2022.