Persius/hicric huggingface dataset:
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 you have only been at the skilled nursing facility 12 
or 13 days and has not had enough time to reach your goal. The Plan denied your request. The Plan says you do 
not meet SNF criteria, the needs were previously and are now custodial in nature. 
 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 have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 pay for Epoetin alfa injection and hemoglobin count provided on 
August 18, 2022. 
 
You asked the Plan to pay for Epoetin alfa injection and hemoglobin count. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says the provider would need to bill Original Medicare as 
member was enrolled in hospice on 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 Epoetin alfa injection and hemoglobin count provided on 
August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided June 30, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the equipment was prescribed by 
the doctor and issued to the enrollee for use during their surgery. The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliances (E0673) provided June 
30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
services in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation states that all acute medical conditions have resolved 
and does not specify any complex functional impairments.  Thus, the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be 
expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
IRF criteria are not 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that the enrollee needs this 
loop recorder. The Plan denied your request. The Plan says the implantable loop recorder is only needed if the 
enrollee has had a stroke or fainting spell of unknown cause and noninvasive monitoring has been done for 3 
weeks without providing a diagnosis. The enrollee does not meet these criteria. 
 
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 pre-approve an implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke, or any other apparent indication for an ICM. In summary, there is insufficient 
documentation to support the medical necessity for insertion of an ICM in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94762 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code(s) 94762. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code(s) 94762. Based on this 
information, we decided that Medicare rules for coverage of procedure code 94762 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 94762 billed for date of service 
May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 20, 
2021, to September 21, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient stay was medically 
necessary. The Plan denied your request. The Plan says observation services would have been more 
appropriate. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found as the enrollee quickly improved with initial treatment and was otherwise stable 
without severe or complex clinical circumstances, it was not expected that the enrollee would require hospital 
services that would likely cross 2 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 care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided September 20, 2021, to September 21, 
2021.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services provided on August 6, 2022. 
 
You asked the Plan to pay for the transportation services. You say that the enrollee was not an inpatient on the 
date of service. The Plan denied your request. The Plan says that payment was included in the hospital 
payment. 
 
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. 
 
We looked at the file and the rules. The file shows that the enrollee was provided ambulance transportation 
from their residence to the hospital. The Plan has not provided documentation to show that payment for the 
services at issue were provided to the hospital. There is no indication that the provider is an institutional-based 
provider. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the ambulance 
transportation services provided on August 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain ceramic crown (D2740) provided on September 
8, 2022. 
 
You asked the Plan to pay for the porcelain ceramic crown. You say that you would like this claim covered. 
The Plan denied your request. The Plan says this claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the porcelain 
ceramic crown with 20% coinsurance up to the $2,500 annual allowance. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you were asked to 
pay 20% coinsurance for the crown. The claim was then covered up to your $2,500 dental allowance. You have 
also been asked to pay to remaining amount above the dental allowance. Based on this information, we decided 
that the Plan's rules for coverage of the porcelain ceramic crown have not been met. Therefore, we decided that 
the Plan does not have to pay for the porcelain ceramic crown (D2740) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the enrollee needs to start treatment. The 
Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 radiation therapy have been met. No 
supporting medical records were submitted to the Plan for this case. The Plan requested additional medical 
records but none were submitted. Without medical records, we cannot determine whether the enrollee meets 
criteria for the requested radiation therapy. Please submit supporting medical records to the Plan. Therefore, we 
decided that the Plan does not have to pre-approve radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services (90999, J2916, Q5105) provided on April 
12, 2022 to April 30, 2022. 
 
You asked the Plan to pay for the dialysis services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 codes 90999, J2916, & Q5105 are not supported in the medical record. Specifically, code 
G0491 must be used for dialysis for an acute kidney injury in a Medicare-certified ESRD facility. Based on this 
information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, 
we decided that the Plan does not have to pay for dialysis services (90999, J2916, Q5105) provided on April 
12, 2022 to April 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service August 17, 
2022. 
 You asked the Plan to pay for procedure code 11721. The Plan denied your request. The Plan says payment for 
code 11721 is bundled into payment for code 11055. 
 
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 11721 is a column II code to column I code 11055. The code at issue 
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 procedure code 
11721 billed for date of service August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gene panel testing provided on June 6, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the gene testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for gene panel testing provided on June 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on January 26, 2022. 
 
You asked the Plan to pay for ambulance transport. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
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 ambulance transport provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88108 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 88108. You say that the procedures should not be bundled. The 
Plan denied your request. The Plan says payment for code 88108 is bundled into payment for code 88187. 
 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 88108 is a column II code to column I code 88187. The code at issue 
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 procedure code 
88108 billed for date of service May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pay for hospital services, taxi transportation, and prescription drugs provided in the 
Kingdom of Spain on May 2, 2022. You say that this was a necessary procedure and should be covered. The 
Plan says that this treatment was for a pre-existing condition and was a foreseen event. 
 
We decided that the Plan has to pay for hospital services.  
 
The Plan follows Medicare rules. Medicare rules state that items and services obtained outside of the United 
States are not covered except in the specific circumstances described in the previous section. The Plan has a 
worldwide coverage benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to 
this case. The Plan covers worldwide emergency and urgent care including emergency ambulance 
transportation. 
 
We decided that the hospital services you received ashore in Spain do meet prudent layperson for emergency 
care. You were diagnosed with invasive squamous cell carcinoma kerantoachanthoma-type in December 2021 
and your treating provider recommended surgical excision if you developed new lesions that failed to heal, 
ulcerated, or bled. Then  on April 30, 2022 while aboard a cruise ship  you experienced growth in the tumor 
that broke, ulcerated, and bled. Although knowledge of your condition was pre-existing, the sudden change in 
your condition would lead a prudent layperson with an average knowledge of medicine to reasonably expect 
that the absence of immediate medical care to seriously jeopardize their health. You then presented to a 
hospital at the next possible port where your emergency condition was evaluated and stabilized. Therefore, we 
decided that the Plan has to pay for hospital services. 
 
We also decided that the Plan does not have to pay for taxi transportation and prescription drugs. 
 
The Plan follows Medicare rules. Medicare rules state that Medicare does not pay for taxi transportation 
services. Medicare rules also state that self-administered drugs are not covered except in specified 
circumstances. 
 
While the Plan does cover worldwide transportation services, this coverage only applies to ambulance 
transportation and does not cover non-ambulance vehicles. Additionally, the self-administered drugs you 
received are not covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for taxi 
transportation and prescription drugs. 
 
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. 
 
Coverage for self-administered drugs may be available through Medicare Part D benefits. Please contact your 
Medicare Part D plan for more information about coverage.