Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary for you to receive more 
therapy before returning home. The Plan denied your request. The Plan says the services are no longer 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing or therapy needs. Your medical needs 
can safely be met at a lower level of care. Continued care at a skilled nursing facility no longer 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
September 15, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this service was billed with a 
place of service of 22 (outpatient hospital). Code 85060 is inappropriate to be billed with place of service 22 
with professional services . Based on this information, we decided that Medicare rules for coverage of the 
blood smear services have not been met. Therefore, we decided that the Plan does not have to pay for the blood 
smear services coded 85060 provided on September 15, 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 you have failed home therapy and it is necessary for 
you to receive inpatient therapy services. The Plan denied your request. The Plan says you do not meet the 
requirements for inpatient rehab services, your care can be received at an alternate setting. 
 
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 do not require treatment by multiple therapies. While the medical record 
supports 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2331 x 2, D2392, D2332, 
D2335 and D2391 x 2) provided from September 6, 2022, to September 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that all your dental work was not covered, and you 
want to appeal the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 30, 2022. 
Therefore, we decided that the Plan does not have to pay for the resin-based composites (D2331 x 2, D2392, 
D2332, D2335 and D2391 x 2) provided from September 6, 2022, to September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37221 billed for date of service September 8, 
2022. 
 
You asked the Plan to pay for procedure code 37221. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 37221 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 37221 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 37221 billed for date of service September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction and the office visit provided on September 21, 
2022.  
You asked the Plan to pay for the refraction. You say that the service was previously covered. The Plan denied 
your request. The Plan says the refraction is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The refraction service you asked the Plan to pay for is considered a routine vision service. Therefore, we 
decided that the Plan does not have to pay for the refraction and the office visit provided on September 21, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital inpatient or observation discharge day management 
provided to the enrollee on July 6, 2022. 
 
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 records do not support the services billed. 
 
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 99239 is "Hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, there is no 
documentation of a complex hospital discharge note that would support the billing code for 99239 on 7/6/2022 
or 7/7/2022. 
 We looked at this coder's review, the file, and Medicare rules. 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 hospital inpatient or observation discharge day management provided to the enrollee on July 6, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drugs coded J3490 provided on May 24, 
2022. 
 
You asked the Plan to pay for the unclassified drugs. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says payment for this service is included in the global package. 
 
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 J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this drug service was 
provided on the same date of service as a surgical procedure. Code J3490 was not billed with an appropriate 
modifier. This means that this code is included within the global surgery period for the surgery procedure. This 
code is not separately payable as billed. Based on this information, we decided that Medicare rules for coverage 
of the unclassified drugs have not been met. Therefore, we decided that the Plan does not have to pay for the 
unclassified drugs coded J3490 provided on May 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for lumbar laminectomy. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this procedure is highly recommended. 
The Plan denied your request. The Plan says studies have not shown that this is helpful for treatment of the 
enrollee's health problem. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for lumbar laminectomy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.ds Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a trastuzumab injection provided to the enrollee on July 30, 
2022. 
 
You asked the Plan to pay for the injection. You say that this aws medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and not recognized. 
 The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 injection. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there are no 
records provided to indicate the patient's diagnosis and rationale for the use of trastuzumab. Without this the 
service is not reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a trastuzumab injection provided to the enrollee on July 30, 2022.
Appeal type: Drugs
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for outpatient hospital services. We decided that the Plan 
does not have to hold you harmless for self-administered drugs.  
 
You asked the Plan to hold you harmless for outpatient hospital services and self-administered drugs provided 
from February 11, 2022, to February 15, 2022.. You say that more of these charges should be covered. The 
Plan says that these services processed correctly. 
 
We decided that the Plan has to hold you harmless for outpatient hospital services.  
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to apply a $3,072.90 coinsurance to the appealed outpatient hospital services. The Explanation of 
Benefits included in the case file shows that multiple charges from the original claim were consolidated into 
one line with the coinsurance applied. After multiple requests, the Plan has not provided information about the 
specific services or claim lines the coinsurance was applied to. Without this information, it cannot be verified 
that the coinsurance was applied correctly. Therefore, we decided that the Plan has to hold you harmless for 
outpatient hospital services.  
 
We also decided that the Plan does not have to hold you harmless for self-administered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to hold you harmless for self-administered 
drugs. 
 
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 laboratory services coded 82378 and 86304 provided on 
June 10, 2022.  
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 laboratory testing at issue in this appeal 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 coded 82378 and 86304 provided on June 10, 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 you need to learn how to walk and take care of 
yourself again. The Plan denied your request. The Plan says you can receive services in another setting such as 
in a skilled nursing facility or skilled therapies at home. 
 
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 do not require treatment by multiple therapies. While the medical record 
supports 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an addition to lower extremity, above knee, air, fluid, gel or equal, 
cushion socket (L5648) and a custom shaped protective cover, above knee (L5705). 
 
You asked the Plan to pre-approve lower limb prosthesis. You say that you disagree with the denial. The Plan 
denied your request. The Plan says that the requested prosthetics are not medically reasonable and necessary 
for coverage per the CMS guidance. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 lower limb prosthesis. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found Medicare does not provide specific rules about when a gel cushion or protective 
cover should be added. You have pinching in your current socket and are very active. Waterproof covering is 
reasonable, and the plan has not provided a reason why it is not appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthesis have been met. Therefore, we decided that the Plan has to 
pre-approve an addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket (L5648) and a 
custom shaped protective cover, above knee (L5705).  
 
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 laboratory services coded as 81225, 81226, 81227, 
81230, 81231, 81232, 8140, 81241, 81291, 81306, 81328, 81355, 81355, 81401, 0031U, 0032U, 0033U, 
81479, 81407, 81406, 81238 provided May 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says that 
additional information is needed in order to consider this claim. 
 
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 laboratory services. 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 the genetic 
testing services provided on May 23, 2022, at issue in this case meet all Medicare criteria for medically 
reasonable and necessary for the patient, per Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 
411.15(k). Provided records document the testing was performed to determine the effectiveness of the 
enrollees current medication regimen but records do not document any current concerns with their medical 
conditions or medical treatment or medication regimen which would require genetic testing to evaluate. The 
latest notation in the records with regard to the enrollees cardiac disease was a coronary intervention from 
2004. Provided records from the enrollees treating physician do not describe how the results of the testing 
would be used in the current care of her medical conditions. Medical records indicate the testing was ordered at 
the request of the 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 81225, 81226, 81227, 81230, 81231, 81232, 8140, 
81241, 81291, 81306, 81328, 81355, 81355, 81401, 0031U, 0032U, 0033U, 81479, 81407, 81406, 81238 
provided May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystic fibrosis transmembrane conductance regulator (CFTR) 
gene analysis (81220) and survival of motor neuron 1, telomeric (SMN1) gene analysis (81329) provided on 
September 1, 2022. 
 
You asked the Plan to pay for the CFTR and SMN1 gene analysis. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says these screening tests are excluded from coverage. 
 
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, the CFTR and SMN1 gene analysis, 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 cystic fibrosis transmembrane conductance regulator (CFTR) gene analysis (81220) 
and survival of motor neuron 1, telomeric (SMN1) gene analysis (81329) provided on September 1, 2022.