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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services 
you and/or your provider are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be improving but is still somewhat unstable due to 
waxing and waning mentation and should only require short-term additional acute care services that can safely 
be administered at the current facility until more stable and appropriate for a lower level of care. The enrollee 
does not require services at the LTACH that are not already available and covered at the current facility. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it would not 
be clinically advantageous. Completion of treatment at the current facility is recommended at this time.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis procedure and dialysis services to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve dialysis procedure and dialysis services. You say that you know the nurses, 
employees, and you are happy with the service you receive at the requested provider. You also say that in the 
other unit you will not have the same opportunity to get in, and a different turn would affect you. The Plan 
denied your request. The Plan says the requested provider is an out-of-network provider. The Plan also says 
that they have a contracted dialysis facility that is available for a coordinated care transition to provide the 
same service at a less distance, same time shift and with your current nephrologist. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dialysis procedure and dialysis services to be 
provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 100 routine transportation trips. 
 
You asked the Plan to pre-approve an additional 100 routine transportation trips. You say that you need 
transportation to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 100 routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on April 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for a drug test. 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 authorization is required prior 
to an out-of-network visit. 
 
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 a drug test provided on April 5, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested are not medically necessary. 
 
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 genetic testing provided on April 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on January 3, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you feel the test kits should be 
covered because you needed them to get into a venue. The Plan denied your request. The Plan says these test 
kits were purchased before the Plan's benefit went into effect on February 1, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 test kits is an OTC item. The rules also say that Medicare Advantage plans may cover these tests as 
a supplemental benefit starting January 15, 2022, or prior depending on the specific benefits offered by the 
Plan. The record shows that the Plan began offering a benefit for at-home COVID-19 test kits on February 1, 
2022. You purchased these tests prior to the Plan's effective coverage date of February 1, 2022. Therefore, we 
decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
April 19, 2022. 
 You asked the Plan to pay for the determination of refractive state. You say that this should be covered as a 
routine eye exam because you were under the impression it was just to get new glasses. The Plan denied your 
request. The Plan says your coverage does not provide for this service. 
 
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. The Plan covers these services when it is performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. The record shows that this refraction was performed during a medical 
eye exam. Based on this information, we decided that the Plan's rules for coverage of the determination of 
refractive state have not been met. Therefore, we decided that the Plan does not have to pay for the 
determination of refractive state (92015) provided on April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the 
enrollee does not have a need for multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested wheelchair. Our physician 
reviewer found that the enrollee has paraplegia and is unable to walk and requires minimal assist to transfer. He 
is incontinent and uses diapers. He does not use intermittent catheterization. There are assertions of spasm and 
inability to weight shift but there is no evidence of spasms or tremors. His legs are simply recorded as 0/5 in 
strength. He has been incontinent and confined to a wheelchair for some time. He is not obese. His history does 
not support he is at high risk for skin breakdown and no objective criteria are provided indicating he is 
incapable of weight transfer. Therefore, the criteria are not met for multiple power options for a power 
wheelchair. 
 
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 requested wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services and a psychotherapy visit provided on 
May 5, 2022, by an OON provider. 
 
You asked the Plan to pay for mental health services and a psychotherapy visit. You say that you were advised 
an authorization wasn't needed. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
 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 mental health services and a psychotherapy visit 
provided on May 5, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services do not need authorization. The Plan 
denied your request. The Plan says there was no valid authorization for the out-of-network service. 
   
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 February 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on March 19, 2021. 
 
You asked the Plan to pay for an extraction. You say that you were not aware that the provider had opted out of 
Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately 
contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers. 
 
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.  
 
   
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an extraction have not been met. Specifically, services were provided by an Opt Out provider. The 
Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan 
does not have to pay for an extraction (D7140) provided on March 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service February 6, 
2022. 
  You asked the Plan to pay for procedure code 74176. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment 
for code 74177. 
 
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 74176 
is a column II code to column I code 74177. This claim 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 74176 billed for date of service February 6, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services billed 11012-T8, 11012-T9, and 
28496 provided from November 20, 2021, through November 29, 2021. 
 
You asked the Plan to pay for the outpatient services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has processed 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
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 28496 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 the 
outpatient services as billed have not been met. 
 
 
In addition, code 11012 has a bilateral indicator of 2 on the Physician Fee Schedule. Therefore, the same 
inherent bilateral procedure code is occurring two or more times on the same service date invoking edit 17. The 
required disposition for a claim with this edit is Return To Provider. This means the 
whole claim is returned to the provider. The provider can resubmit the claim once the problem is corrected.  
Therefore, we decided that the Plan does not have to pay for the outpatient services billed 11012-T8, 11012-T9, 
and 28496 provided from November 20, 2021, through November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on March 14, 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 March 14, 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 an office visit provided on February 25, 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 authorization is 
required prior to an out-of-network visit. 
 
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 February 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychosocial rehabilitation services. 
 
You asked the Plan to pre-approve psychosocial rehabilitation services. You say that psychosocial 
rehabilitation services are medically necessary. The Plan denied your request. The Plan says psychosocial 
rehabilitation services are 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 psychosocial rehabilitation services. 
Our reviewer says that psychosocial rehabilitation services are not considered medically reasonable and 
necessary. Our physician reviewer found based on review the records provided, you have had been in this 
treatment previously where you made new friends and improved the quality of life. There is no documentation 
of the severity of your depressive symptomatology based on PHQ 9 score or a psychiatric evaluation. Based on 
review the records provided you do not meet the criteria for psychosocial rehabilitation services based on the 
Medicare LCD L33632 and could be treated at a lesser restrictive environment. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychosocial rehabilitation services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve psychosocial rehabilitation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from March 9, 2022, to 
April 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The 
Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 physical therapy services provided from March 9, 
2022, to April 4, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of IRF admission. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition they 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 the enrollee was admitted for gastrointestinal bleeding and esophageal ulceration. 
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 documentation of a need for an intensive rehabilitation 
program. 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 the IRF admission and services.