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. You say that it could jeopardize your health not getting these 
services. 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 rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement, however, the documentation doesnt support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain her functional status. You can receive further services at a 
lower level of care. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit for a computed tomography (CT) of the 
spine (procedure code 72125) provided to the enrollee on January 17, 2022.  
You asked the Plan to pay for the additional unit. You say that this should be paid for. The Plan denied your 
request. The Plan says only one unit can be overturned and paid. 
 
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 72125 is "Computed tomography, cervical spine; without 
contrast material." 
 
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 additional unit. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that there are no records of a 
CT of the cervical spine done on January 17, 2022. 
 
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 additional unit have not been met. Therefore, we decided that the Plan does 
not have to pay for an additional unit for a computed tomography (CT) of the spine (procedure code 72125) 
provided to the enrollee on January 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has tried and failed an oral bisphosphonate. 
You also say that given the side effects the enrollee did not want to try the intravenous version. The Plan 
denied your request. The Plan says the enrollee has not tried and failed bisphosphonates, oral and intravenous, 
for at least one year. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative. The record does not sufficiently indicate 
that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one 
alternative. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services (A0425, A0428) 
provided on February 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergency ambulance services. You say that you are requesting retro 
authorization and reimbursement for the services. The Plan denied your request. The Plan says no prior 
authorization was obtained for the services at issue. 
 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 non-emergency ambulance services (A0425, 
A0428) provided on February 10, 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 Covid-19 testing provided on February 9, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test was required for re-entry into the 
country. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
 The test at issue in this appeal was requested solely for screening purposes. It is considered a screening since it 
was for traveling and not because of signs or symptoms from exposure to Covid-19. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Covid-
19 testing provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the service as it 
was not clear that you reached the frequency limit. 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 February 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no medical documentation to support the need for a portable oxygen 
concentrator. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found that you 
have hypoxemia following COVID pneumonia. You use a walker and are unable to manage portable tanks with 
the walker. However, Medicare requires evidence that SpO2 can be maintained more than 91% during activity 
using an oxygen conserving device and flow rate 1 to 4 L/min. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services you received on September 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you did not know that you shouldn't go to this lab. 
The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that "Use additional code notes are found in the 
Tabular List at codes that are not part of an etiology/manifestation pair where a secondary code is useful to 
fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, use additional 
code indicates that a secondary code should be added, if known.  
 
We looked at the file and Medicare rules. In this case, the lab services were billed with secondary diagnosis 
code Z00.01. However, this code has a "use additional code" note, which means that this code must be 
sequenced as the primary diagnosis code when billed with multiple conditions. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services you received on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for fillings (D2392, D2393) provided on 
June 7, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were told the services 
would be covered. The Plan denied your request. The Plan says your annual maximum benefit 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 June 7, 2022. Therefore, 
we decided that the Plan does not have to pay an additional amount for fillings (D2392, D2393) provided on 
June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiomyopathy risk factor screening panel (81408, 81406, 
81404, 81407, 81405, 81439, 81286 and 81403) billed for date of service August 1, 2021. You asked the Plan to pay for a genetic panel. You say that these services were necessary, and they were 
performed by an accredited laboratory. The Plan denied your request. The Plan says there is insufficient 
information to show that this testing was ordered by a physician who is treating the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that diagnostic laboratory tests must be ordered by the 
physician who is treating the beneficiary. Tests not ordered by a physician who is treating the beneficiary are 
not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory have been met. Specifically, 
the submitted records do not contain a physician order which shows that a provider who is treating the enrollee 
ordered these services with clear intent. In addition, no medical records or progress note were provided to 
support the medical necessity of this testing. Therefore, we decided that the Plan does not have to pay for a 
cardiomyopathy risk factor screening panel (81408, 81406, 81404, 81407, 81405, 81439, 81286 and 81403) 
billed for date of service August 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen validity testing (procedure code 83789) provided 
to the enrollee on February 7, 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 Current Procedural Terminology (CPT) code 83789 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for specimen validity testing (procedure code 83789) provided to the enrollee on February 7, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the shoulder x-ray provided on April 29, 
2022. 
 
You asked the Plan to waive the copayment for the shoulder x-ray. You say that you did not need any x-rays 
and they did not tell you this was chargeable. You say that you wouldn't have done it if they would have told 
you it was chargeable. The Plan denied your request. The Plan says the copayment applied 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 $30 
copayment for each basic imaging service.  
  You have been asked to pay a $30 copayment for the shoulder x-ray. The shoulder x-ray falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 the shoulder x-ray provided on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on October 25, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81479) provided on October 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 31, 2021, to February 26, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the Plan did 
not receive the initial RAP claim within 5 calendar days. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from January 31, 2021, to February 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on April 
8, 2022. 
 
You asked the Plan to waive the coinsurance for an aflibercept injection. You say that this cost share is too 
costly, you were not expecting it to be that high. The Plan denied your request. The Plan says the coinsurance 
was applied 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs. The allowed amount of this item is 
$3656.80, resulting in a coinsurance amount of $731.36 ($3656.80 x 20% = $731.36). 
 
You have been asked to pay a $731.36 coinsurance for an aflibercept injection. An aflibercept injection falls 
within the Medicare Part B Non-Chemotherapy Prescription Drugs 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 coinsurance for an aflibercept injection provided on April 8, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or 
therapy needs. You are ambulating household distances. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs are custodial and 
intermittent and can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services should be covered as you disagree 
with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as they are non-emergent and can be 
provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.