Persius/hicric huggingface dataset:
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 you do not have 
complex care needs that require a coordinated team approach. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for non-surgical management of a radial fracture and pelvic 
fractures after a fall. Your medical problems are stable. While you have a need for physical and/or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 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 prosthetic leg with an advanced knee/foot feature for the 
enrollee. 
 
You asked the Plan to pre-approve the feature. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request does not meet the criteria for being reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 feature. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the provider has documented that the enrollee is expected to be K3 level as his rehabilitation 
proceeds. The plan denied this request due to a disagreement with patient activity level; however, this was 
based on the assistive devices that the enrollee was using early on in the recovery phase. 
 
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 feature have been met. Therefore, we decided that the Plan has to pre-
approve a prosthetic leg with an advanced knee/foot feature for the enrollee.   
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-participating fitness center membership purchased 
June 2, 2022. 
 
You asked the Plan to pay for a non-participating fitness center membership. You say that your regular gym 
closed due to COVID-19. The Plan denied your request. The Plan says this membership is not covered because 
it is an out-of-network facility. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when you select a provider in the Plans network. 
 
The Plans rules for coverage of gym benefits have not been met because this is not a participating fitness 
center. Therefore, we decided that the Plan does not have to pay for a non-participating fitness center 
membership purchased June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the determination of refractive state (92015) provided on February 16, 
2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that you thought an eye refraction 
exam would be covered. The Plan denied your request. The Plan says that eye refractions are only covered by 
your plan if performed by a participating vision provider and performed as a routine screening. The Plan also 
says that per the office, you received a medical eye refraction for the diagnosis of age-related nuclear cataract. 
 
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 any medical records for this case. Without this 
information we cannot determine that the Plan's coverage rules support the denial of payment in this case. The 
records show that the enrollee received a routine eye exam on this same date of service, and refractions are 
covered during routine exams. Consequently, the Plan has not substantiated their denial of payment in this case. 
Therefore, we decided that the Plan has to pay for the determination of refractive state (92015) provided on 
February 16, 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 pay for the electrical stimulator supplies coded A4595 provided on 
November 7, 2021. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the items 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. 
 
In this case, the CPT Code Manual definition of code A4595 is electrical stimulator supplies, 2 lead, per month, 
(e.g., tens, nmes). 
 
We find that CPT code A4595 is not supported in the medical record. Specifically, these items are considered 
part of the same procedure and therefore, are bundled. No separate payment can be made. Based on this 
information, we decided that Medicare rules for coverage of the electrical stimulator supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies coded 
A4595 provided on November 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF coded as 81206, 81210, 81235, 81275, 81276, 
81292, 81295, 81298, 81317, 81401, 81301, 81191, 81309 provided September 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request that the Plan reconsider this 
determination and cover the Tempus Gene panel test at the in-network benefit level. The Plan denied your 
request. The Plan says the request for Tempus xF does not meet Medicare rules as the testing performed was 
not FDA approved. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for Tempus xF coded as 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 
81191, 81309 provided September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you must go to inpatient rehabilitation because they 
have specialized equipment you need for rehabilitation. The Plan denied your request. The Plan says that the 
services you need can be provided safely in other settings. 
 
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for cervical spine surgery. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026), provided on August 18, 2021, 
through September 22, 2021. 
 
You asked the Plan to pay for the infrared therapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that he use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the 
symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory 
neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026), provided on August 18, 2021, through September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (87486, 87581, 87631, 87637, 87798) 
provided on September 29, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this testing was not ordered by the physician 
who signed the order. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Specifically, the record indicates that this testing was not 
ordered by the enrollee's treating physician. Therefore, we decided that the Plan does not have to pay for the 
genetic testing (87486, 87581, 87631, 87637, 87798) provided on September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transluminal thrombectomy (36906) 
provided on November 1, 2021. 
 
You asked the Plan to pay for the percutaneous transluminal thrombectomy (36906). You say that the doctor 
had to perform surgery and the documentation should be reviewed for payment. The Plan denied your request. 
The Plan says procedure codes 36831, 99233 and 76000 have been overturned. The Plan also says there is no 
modifier allowed for CPT code 36906 to bypass the code edit. 
  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 36906 
is a column II code to column I code 36831 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 percutaneous transluminal thrombectomy (36906) provided on November 
1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist x-ray (73110) provided on August 6, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on August 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the wrist x-ray 
(73110) provided on August 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found records do not document the need 
for intravenous medications, new tube feeding, ostomy care or daily complex wound care. The enrollee is 
walking household distances with a rolling walker with contact guard assistance and is supervision to contact 
guard assist for transfers. Provided records do not document a significant decline in the enrollees functional 
status to necessitate daily inpatient skilled therapy services. The enrollee does not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the home 
with home health care or in a long-term care facility on a part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the hospital discharge day management (99239). You say that the medical 
records support the level of care and the claim should be reprocessed accordingly. The Plan denied your 
request. The Plan says the medical records submitted do not support a hospital discharge management of more 
than 30 minutes was performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
  In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not document 
hospital discharge management of 30 minutes or more was performed as required by the CPT code billed. 
Based on this information, we decided that Medicare rules for coverage of the hospital discharge day 
management (99239) have not been met. Therefore, we decided that the Plan does not have to pay for the 
hospital discharge day management (99239) provided on January 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says services provided by an out-of-network are not covered without prior 
authorization. 
 
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 provided on January 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 the genetic testing services provided on May 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for breast tomosynthesis (77062) provided on October 1, 2021. 
 
You asked the Plan to pay for breast tomosynthesis. You say that this is a valid procedure and is supported for 
the date in question. The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
Medicare uses a different code to report this 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. 
 
We find that CPT code 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay 
for breast tomosynthesis (77062) provided on October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings identified with code A6533 that were 
issued on February 1, 2022. 
 
You asked the Plan to pay for compression stockings. You say that the requested items were a medical 
necessity for you. The Plan denied your request. The Plan says rules for payment for compression stockings 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for compression stockings 
identified with code A6533 that were issued on February 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on January 2, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you do not have anything for this date 
of service in your appointments or past calendar. The Plan denied your request. The Plan says the drugs you 
received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare 
Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part 
B. 
 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 pay for the self-administered drugs 
provided in an outpatient setting on January 2, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.