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

 
We decided that the Plan does not have to pay for lab services provided on May 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. 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 lab services provided on May 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 14, 2021, to February 18, 2021. 
 
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 reassignment of the DRG for this inpatient admission was appropriate.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 100 (SEIZURES WITH MCC). 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our physician reviewer found the clinical documentation 
did not support that the following diagnoses impacted this hospital admission-- G93.41 Metabolic 
encephalopathy and F10.129 Alcohol abuse with intoxication, unspecified. The billed DRG is 100 Seizures 
with MCC. Based upon the Uniform Hospital Discharge Data Set (UHDDS) rules, the corrected DRG 897 
Alcohol, drug abuse or dependence without rehabilitation therapy without MCC is more accurate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from February 14, 2021, to February 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional PT visits. 
 
You asked the Plan to pre-approve additional PT. The Plan denied your request. The Plan says there is no 
documented failure to respond to a home exercise program (HEP) and/or indication that residual deficits could 
not be addressed within the context of a self-directed home exercise program. Therefore, given the provided 
documentation, you do not meet the guidelines for the requested service which does not appear medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 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 additional PT. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is accepted as specific 
and effective therapy for your condition. You have had prior therapy and the documentation does not reveal 
that you require the unique skills of a professional therapist to safely and effectively provide treatment, or that 
the services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. You are trained in a home exercise program and near baseline function. The requested services are 
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain your current condition or to prevent or 
slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that this is medically necessary. 
The Plan denied your request. The Plan says that you are not insulin-treated with multiple (three or more) daily 
injections. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0013M) provided on September 29, 
2021. 
 
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this 
testing is a medically necessary and covered by Medicare. The Plan denied your request. The Plan says this 
testing is not a Medicare covered benefit. 
 
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 CxBladder testing. Our reviewer says 
that CxBladder (0013M) does not meet Medicare's criteria of being medically reasonable and necessary. Our physician reviewer found urinary biomarker tests such as CxBladder give significant false-negative results in 
patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage 
and low-grade tumors. 
 
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 CxBladder testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the CxBladder testing (0013M) provided on September 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy visits 
and treatment. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says at this time, an evaluation with an internal provider who can provide Schroth therapy 
would be more appropriate. 
 
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 a network provider 
available who is certified in Schroth. 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 an out-of-network referral for 
physical therapy visits and treatment.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not meet Medicare criteria for coverage of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Entyvio. Our reviewer says that 
Entyvio is medically necessary. Our physician reviewer found the Food and Drug Administration has stated 
that the requested drug is indicated for the enrollee's condition. The Food and Drug Administration has not 
specifically limited dosing frequency. The request meets Medicare 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 Entyvio have been met. Therefore, we decided that the Plan has to pre-approve 
Entyvio.  
 
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 group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 2 power wheelchair and accessories. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a power 
wheelchair have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 2 power wheelchair and 
accessories. Our reviewer says that the requested power wheelchair is not medically reasonable and necessary. 
Our physician reviewer found the documentation does reveal a mobility deficit. The documentation does not 
support that the mobility deficit impairs MRADLs in the home and this mobility limitation is not ameliorated by a rollator. The patient can perform most MRADLS with her rollator. While the patient may have the 
cognition to safely operate the requested power mobility device the requested Group 2 K0837 wheelchair and 
accessories are not medically necessary per Medicare coverage 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 group 2 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-rays rendered on September 26, 2021. 
 
You asked the Plan to pay for these services. You say that the services are not covered. The Plan denied your 
request. The Plan says that [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 provided a clear denial reason in the submitted documentation. 
The exact procedure codes of the denied services are not provided, nor has the Plan provided any Medicare 
rules to support that the services are not payable as billed. Therefore, we decided that the Plan has to pay for 
the x-rays rendered on September 26, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the procedure to remove a skin lesion. 
 
You asked the Plan to pre-approve the procedure to remove a skin lesion. You say that this is necessary for 
your health due to previous circumstances. The Plan denied your request. The Plan says the criteria for 
coverage have not been met in this case. 
 
The Plan follows Medicare rules. Medicare rules say that removal of skin lesions is subject to the criteria listed 
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 the procedure to remove a skin lesion. 
Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician 
reviewer found the record indicates that the enrollee has a skin lesion she wishes to have removed. The record 
indicates that the provider's opinion is that this is a benign lesion. The records do not indicate the presence of 
criteria that warrant removal. The provider has indicated removal is for cosmetic purposes. The elements of the 
coverage criteria are not 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 the procedure to remove a skin lesion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the procedure to remove a skin lesion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided to the enrollee on September 16, 
2021. 
 
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, we have confirmed that code 71045 
is a column II code to column I code 74022. 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 services provided to the enrollee on September 16, 2021.
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 the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 you appear to not be improving significantly with current treatment and is still not 
stable for transfer and requires short-term additional acute care services to further stabilize until more 
appropriate for transfer. Care can be safely administered at the current facility until this time. You do not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that you require that are not already available and covered at the current facility. Transfer to LTACH 
is not medically necessary at this time. Transfer may be considered when treatment has completed and you are 
more stable. 
 
 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 pay for the outpatient hospital services provided November 2, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that you are submitting medical records to 
support medical necessity. Please review and process the claim for payment. The Plan denied your request. The 
Plan says that there is another payer that is primary and the claim must be submitted to the primary carrier.  
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
insurance that is primary. As the secondary insurer, the Plan cannot be held responsible for the outpatient 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the outpatient hospital services provided November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital admission for knee arthroplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the enrollee should be 
admitted for the procedure. You also say that you are not certain which admission status will be necessary until 
the actual surgery. The Plan denied your request. The Plan says the inpatient admission is 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 admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the provided documentation does not indicate that the enrollee requires 
inpatient hospital services for the elective knee procedure. The reviewer found that the record did not show that 
at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient hospital admission for knee arthroplasty.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the cost sharing for a mental health telehealth visit provided on October 
29, 2021. 
 
You asked the Plan to reduce the cost sharing for a telehealth visit. You say that you feel you should have to 
pay a $35 specialist visit copayment. You also say that in the past for the same service you were only charged 
the $35 copayment. The Plan denied your request. The Plan says that you have been charged the correct cost 
sharing amount. 
 
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 did not provide medical records to show who you specially saw, or if 
the provider you saw was a specialist. Without the medical records we are unable to determine if the deductible 
applies. Therefore, we decided that the Plan has to waive the deductible and reduce the cost sharing for a 
mental health telehealth visit provided on October 29, 2021, to a $35 copayment. 
 
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.