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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is physically and medically necessary for 
the enrollee to return home at her maximum level of functioning with a decreased risk for readmission. The 
Plan denied your request. The Plan says that criteria for admission to the IRF setting have not been met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation clearly shows the medical complexity of this case in which the enrollee 
would benefit from close medical supervision, admitted on an inpatient basis focused on rehabilitation. The 
enrollee has documented functional impairments in both physical therapy and occupational therapy. The 
evaluating therapist recommends intense rehabilitation in an IRF setting. An IRF admission is medically 
reasonable and necessary based on clinical documentation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Estrace vaginal cream 0.01%. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Estrace is a self-administered drug and does not fall under Part B coverage. 
 
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 pre-approve Estrace vaginal cream 
0.01%.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination regime of Opdivo, Yervoy, Carboplatin, 
and pemetrexed. 
 
You asked the Plan to pre-approve Opdivo, Yervoy, Carboplatin, and pemetrexed. You say that the enrollee's 
life is at risk and depends on this treatment. The Plan denied your request. The Plan says the denial of 
authorization for these drugs is correct, because the regimen requested is not considered safe and effective for 
the enrollee. 
 
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 pre-approve Opdivo, Yervoy, Carboplatin, and 
pemetrexed. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested 
chemotherapy combination. Our physician reviewer found the requested use of Opdivo, Yervoy, Carboplatin, 
and pemetrexed is not Food & Drug Administration (FDA) approved for the enrollee's condition of squamous 
cell histology. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo, Yervoy, Carboplatin, and pemetrexed have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a combination regime of Opdivo, Yervoy, Carboplatin, 
and pemetrexed.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services in dispute were not related to 
the enrollee's illness. You say that the medical records provided support the need for reimbursement. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the enrollee's terminal condition for the date of service in dispute. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on September 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted gnomic sequence analysis (0037U) provided 
December 31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare ules for coverage of the laboratory services have not been 
met. Therefore, we decided that the Plan does not have to pay for the targeted gnomic sequence analysis 
(0037U) provided December 31, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the radiologic examination, wrist (73110) provided October 29, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that you billed the claim to the PMG as directed 
by the Plan. You are attaching the PMG denial and a copy of the authorization from the Plan. You ask for 
review of the documentation and send back the claim through for processing. The Plan denied your request. 
The Plan says that the claim was submitted without the critical access rates sheet. 
 
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 deny your request. the Plan has not substantiated their reason to continue to deny the claim. There 
are no applicable Medicare rules which require a rate sheet to be included with critical access hospital requests 
and appeals. Therefore, we decided that the Plan has to pay for the radiologic examination, wrist (73110) 
provided October 29, 2021.  
 
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. 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 your medical and rehabilitation needs do not require the intensive interdisciplinary 
approach provided in acute inpatient rehabilitation. You do not meet the requirements for intensive 
rehabilitation therapy three hours a day and five days a week or 15 hours over seven consecutive days. 
 
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 a K3 foot and Ossur Mauch K3 knee. 
 
You asked the Plan to pre-approve a K3 foot and Ossur Mauch K3 knee. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 K3 foot and Ossur Mauch K3 knee. 
Our reviewer says that the services are medically necessary. Our physician reviewer found clinical 
documentation specifically outlines a K3 functional level with advanced activities that would require 
microprocessor prosthetic joints. K3 foot and Ossur Mauch K3 knee are medically reasonable and necessary 
and meet LCD criteria. 
 
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 K3 foot and Ossur Mauch K3 knee have been met. Therefore, we decided that 
the Plan has to pre-approve a K3 foot and Ossur Mauch K3 knee.  
 
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. You say that the enrollee currently meets IRF admission criteria 
under the Centers for Medicare and Medicaid Services (CMS) guidelines. The Plan denied your request. The 
Plan says this does not meet criteria, is not medically necessary, and a lower level of care might be appropriate. 
 
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy. 
 
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 pre-approve contact lens, scleral, gas permeable (V2531). 
 
You asked the Plan to pre-approve scleral contact lenses. You say that these contact lenses are necessary to 
treat the enrollees condition. The Plan denied your request. The Plan says these contacts are not covered by 
Medicare. The Plan offers a supplemental vision benefit which allows up to $600 per year for covered services. 
The Plan will apply the enrollee's vision benefits; however, the cost which exceeds this benefit allowance is not 
covered. 
 
The Plan must follow Medicare rules. Medicare generally does not cover routine vision and eyewear services. 
Scleral contacts, when used for non-covered conditions and billed with code V2531, are among those 
items/services excluded from Medicare coverage. 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 up to $600 per year. 
 
We looked at the file and Medicare rules. The requested services are not covered by Medicare, and the 
projected cost of these contact lenses exceed the Plans $600 supplemental benefit allowance. While these 
lenses may be covered up to the $600 limit, the projected cost of these items exceeds this allowance and will 
not be paid in full. Based on this information, we decided that Medicare rules for coverage of scleral contact 
lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve contact lens, 
scleral, gas permeable (V2531).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76705) provided on February 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 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 76705 
is a column II code to column I code 93976. 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 the services (76705) provided on February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray exam of the abdomen, 1 view (74018) provided on 
November 3, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 74019 and 74018. This PTP edit has a modifier indicator of 1, meaning modifiers associated 
with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service 
was not billed appropriately 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, we have confirmed that code 74018 is a column II code to column I code 74019. 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 x-ray exam of the abdomen, 1 view (74018) provided on 
November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections provided on February 8, 2022. 
 
You asked the Plan to pay for facet joint injections. You say that you are appealing withs upporting records. 
The Plan denied your request. The Plan says the denial of payment for these codes is correct, because this code 
has a medically unlikely edit value of 1 and more than 1 unit of this code was billed. 
 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 64494 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 facet 
joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint 
injections provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 3, 2021. 
 
You asked the Plan to pay for the lab services. 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 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 the lab services provided on May 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services provided on July 13, 
2021. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for 
this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care services provided on July 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on December 21, 2021. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code is not separately 
payable when billed for specimen validity testing on specimens used for drug testing. Therefore, this code 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of the mass 
spectrometry and tandem mass spectrometry services have not been met. Therefore, we decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry services coded 83789 provided 
on December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency care, inpatient hospital care 
and ambulance services from January 12, 2022 to January 19, 2022. 
 
You asked the Plan to waive the copayments for emergency care, inpatient hospital care and ambulance 
services. You say that you would like to appeal the cost share. The Plan denied your request. The Plan says the 
cost share 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 a $250 
copayment per one-way trip by ground or air ambulance, a $90 copayment for emergency care, and a $250 
copayment per day, days 1-6, per admission for inpatient hospital care for emergency care, inpatient hospital 
care and ambulance services. The total allowed amount of the claim is $1,840.  
You have been asked to pay a $250 copayment per one-way trip by ground or air ambulance, a $90 copayment 
for emergency care, and a $250 copayment per day, days 1-6, per admission for inpatient hospital care for 
emergency care, inpatient hospital care and ambulance services. Emergency care, inpatient hospital care and 
ambulance services falls within the emergency care, inpatient hospital care and ambulance 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 copayments for emergency care, inpatient hospital care and ambulance 
services from January 12, 2022 to January 19, 2022.