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

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from rehab, returning to 
their baseline and to prevent falls. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0482 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for the billed services. You say that you cannot get prior authorization before the 
services are rendered. The Plan denied your request. The Plan says the records do not support the coding 
criteria. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
G0482 billed for date of service September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and mattress. 
 
You asked the Plan to pre-approve a total electric hospital bed and mattress. You say that you cannot get in or 
out of bed by yourself. The requested bed is medically necessary for you. The Plan denied your request. The 
Plan says the requested hospital bed is not covered by Medicare or your Plan. The height adjustment feature is 
a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265) and mattress.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub (E1399). 
 
You asked the Plan to pre-approve a walk-in bathtub. You say that you disagree with the denial and are 
requesting reconsideration. The Plan denied your request. The Plan says the request is not a covered benefit 
because a walk-in bathtub is not primarily used to serve a medical purpose, and it is useful to a person in the 
absence of illness or injury. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub (E1399).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergency ambulance transportation (A0428) and ground 
mileage (A0425) provided on July 30, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee required transport by ambulance stretcher due to risk for harm if left unattended. You also say that 
it was unsafe to transport the enrollee by any other means. The Plan denied your request. The Plan says that 
this service is denied because it is inappropriately coded based on coding guidelines. The Plan also says 
payment for the procedure was included in the hospital payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Ambulance services may be billed as Part B 
services by the supplier if the ambulance trip is to the SNF for admission. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was discharged from the hospital 
on July 30, 2022, and transported by ambulance to start an admission at a SNF. Based on this information, we 
decided that Medicare rules for coverage of the non-emergency ambulance transportation and ground mileage 
have been met. Therefore, we decided that the Plan has to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on July 30, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee was recently hospitalized for a chronic obstructive pulmonary disease (COPD) 
exacerbation and arterial blood gas (ABG) was consistent with acute on chronic hypercarbic respiratory failure. 
The enrollee has a diagnosis of obstructive sleep apnea (OSA) and has continuous positive airway pressure 
(CPAP) at home but has been intolerant of that as well. Given the enrollee's intolerance of the mask interface, it seems unlikely the enrollee will be able to tolerate a home ventilator. In any case, bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS) has not been tried and shown to fail 
as an outpatient. Medicare does not cover a home ventilator when used his BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee from June 24, 
2022, to June 26, 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 provider did not bill as required by Medicare coding regulations. 
 
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 the denied codes is: 
 
CPT 45400: 
 
Laparoscopy, surgical; proctopexy (for prolapse) 
 
CPT 80048: 
 
Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) 
Sodium (84295) Urea nitrogen (BUN) (84520) 
 
CPT 85014: 
 
Blood count; hematocrit (Hct) 
 
CPT 85018: 
 
Blood count; hemoglobin (Hgb) 
 
CPT 85025: 
 
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential 
WBC count 
 
CPT 96374: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial 
substance/drug 
 
CPT 96376: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential 
intravenous push of the same substance/drug provided in a facility (List separately in addition to code for 
primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) G0378: 
 
Hospital observation service, per hour 
 
HCPCS J1100: 
 
Injection, dexamethasone sodium phosphate, 1 mg 
 
HCPCS J1885: 
 
Injection, ketorolac tromethamine, per 15 mg 
 
HCPCS J2001: 
 
Injection, lidocaine hcl for intravenous infusion, 10 mg 
 
HCPCS J2405: 
 
Injection, ondansetron hydrochloride, per 1 mg 
 
HCPCS J2704: 
 
Injection, propofol, 10 mg 
 
HCPCS J3010:  
Injection, fentanyl citrate, 0.1 mg 
 
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 Medicare classifies CPT 45400 as an 
inpatient only procedure. In this case, the patient was observation status, which is not inpatient. The rest of the 
codes are therefore also not supported. 
 
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 outpatient services provided to the enrollee from June 24, 2022, to June 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three crowns and an extraction, erupted tooth or exposed root 
provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed that your provider was in-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for three crowns and an extraction, erupted tooth or exposed root provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 21, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were in major pain. You also say it was a 
medical necessity to see the provider. 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 Plans 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 March 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (G0483) billed for date of 
service August 29, 2022. 
 
You asked the Plan to pay for definitive urine drug testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the services at issue were 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 pay for definitive urine drug testing. Our reviewer 
says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records do not document the results of a screening drug test that were 
presumptively positive, or the results of a screen that were negative, and this negative finding was inconsistent 
with the enrollee's medical history, or there was no presumptive test available, locally and/or commercially. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive urine drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for definitive urine drug testing (G0483) billed for date of service August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral genicular nerve blocks (64454 x 2). 
 
You asked the Plan to pre-approve the nerve blocks. You say that the enrollee needs this. The Plan denied your 
request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that peripheral nerve blocks will be considered medically 
reasonable and necessary for certain normally temporary conditions. 
 
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 nerve blocks. Our reviewer says that 
the requested nerve blocks are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that the requested services are being requested due to one of the covered 
temporary conditions. Therefore, the reviewer found that the requested nerve blocks are not medically reasonable or 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 nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bilateral genicular nerve blocks (64454 x 2).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy and 
an upper endoscopy (EGD) provided on September 08, 2022. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy and an upper endoscopy 
(EGD). You say that this was a screening and should not have a copayment. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $300 copayment for an in-network diagnostic colonoscopy and an upper 
endoscopy (EGD). This item/service falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 in-network diagnostic colonoscopy and an upper endoscopy (EGD) provided on September 
08, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the record indicates that the enrollee was admitted with acute altered mental status 
falling a fall with head strike in the setting of underlying dementia. The record indicates a concern for closed 
head injury in a geriatric enrollee. The record provided is sufficient to establish a reasonable expectation of a 
length of stay spanning 2 or more midnights, taking into account complex medical factors. The elements of the 
coverage criteria are satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records do not 
show that you require physician supervision by a rehabilitation doctor at least 3 days per week, medically 
necessary care may be provided safely in a different level of care. 
 
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 while you may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that you require this therapy on an intensive IRF level.  
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.