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

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 In this case, the complexity of the members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled care visits. 
 
You asked the Plan to pre-approve home health care. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for home health care is correct. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer 
found the enrollee does not have documented skilled nursing needs, so skilled nursing services are not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health skilled care visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 22, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the insurance should pay for this. 
The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $140 
copayment for Medicare covered radiological diagnostic services such as ultrasounds.  
 
 
 You have been asked to pay $133.59 which is less than the standard $140 copayment for an ultrasound. 
Ultrasounds fall 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 an ultrasound provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on September 13, 
2021, to November 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that these services meet Medicare 
billing guidelines and should be paid. The Plan denied your request. The Plan says unauthorized, non-plan care 
is not covered. 
 
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 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 outpatient mental health services provided on 
September 13, 2021, to November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for hearing aids and related services provided on June 14, 
2021. 
 
You asked the Plan to pay more for the hearing aids. You say that the enrollee is entitled to coverage of these 
hearing aids. The Plan denied your request. The Plan says it has already paid the $2000 allowance for these 
hearing aids, so additional payment is not due. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to $2000 every three years.  Records show that the Plan has agreed to pay $2000 towards 
some of the hearing aids and related services provided on this date.  However, the remaining balance is the 
enrollee's responsibility. Therefore, we decided that the Plan does not have to pay more for hearing aids and 
related services provided on June 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued home health services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says you do 
not require any further skilled needs. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found that you were hospitalized last in February 2022 and has since been medically stable without 
any falls or injuries. The documentation indicates that you are able to ambulate up to 250 feet with a walker 
and supervision. You and your family are educated on a home exercise program. You do not require additional 
skilled services to provide treatment in order to improve your condition or perform a maintenance program to 
maintain your condition or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. Your mobility is improved, and the services of a 
home health aide or social worker are not necessary according to the documentation. Therefore, the requested 
home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued home health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery services provided on December 2, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that you were told that authorization was not 
required. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 provider in this case is not a network provider with the Plan. 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 surgery services provided on December 2, 2021, by an out-of-
network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo (Q5120). 
 
You asked the Plan to pre-approve Ziextenzo. The Plan denied your request. The Plan says this request does 
not meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 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 Ziextenzo. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and Ziextenzo cannot be recommended. Our physician 
reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred 
step one alternative. Our reviewer also found that the record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ziextenzo (Q5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office and debridement visits provided on June 3, 2021 to 
March 4, 2022, by an OON provider. 
 
You asked the Plan to pay for office and debridement visits. You say that you see the provider every 3-4 
months and prior to June 3, 2021 the services were covered, not denied. The Plan denied your request. The Plan 
says the out-of-network services were not authorized. 
 
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 office and debridement visits provided on June 3, 
2021 to March 4, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology, gene expression profiling (0089U) provided 
February 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services at issue here fall well within 
any reasonable definition of medical necessity. The Plan denied your request. The Plan says the Medicare 
criteria has not been met because the records do not state the size of the lesion. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the oncology, 
gene expression profiling (0089U) provided on 02/04/2022 at issue in this case meets the medically necessary  
criteria listed the Local Coverage Determination (LCD) MolDX: Pigmented Lesion Assay L38151 for 
Medicare coverage. Provided records do not document the size of the lesion as required by the LCD. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for oncology, gene expression profiling (0089U) provided February 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that Vertiflex is considered safe and effective. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is 
not medically reasonable and necessary. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental, more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 
16, 2021, through March 23, 2021, and billed with a Health Insurance Prospective Payment System (HIPPS) 
rate code of ODGD1. 
 
You asked the Plan to pay for the SNF care as originally billed. You say that the documentation supports that 
the SNF care as it was originally billed. The Plan denied your request. The Plan says the documentation 
supports a HIPPS code of ODGE1. 
 
The Plan follows Medicare rules. Medicare rules say that payment for SNF services are paid under a PPS  
based on a HIPPS rate code. 
 
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 SNF care as originally billed. Our 
reviewer says that the documentation does not support payment for the SNF care as it was billed by the 
provider. Our physician reviewer found the enrollee is an 80-year-old woman with a history of diabetes, 
hypertension, chronic kidney disease, and a complicated urinary tract infection, who was admitted to the 
hospital on March 10, 2021, with acute metabolic encephalopathy. The enrollee was treated with a 5-day 
course of ceftriaxone. A culture of the urine grew Streptococcus, group B. The enrollee improved, and she was 
discharged on March 15, 2021, in stable condition. In this case, the clinical documentation does not support 
that the enrollee had infection with a multi-drug resistant organism. Consequently, the plan's revision to 
ODGE1 is supported. 
 
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 SNF care as originally billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 16, 2021, through 
March 23, 2021, and billed with a Health Insurance Prospective Payment System (HIPPS) rate code of 
ODGD1.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is in need of aggressive acute inpatient 
rehabilitation of 3 hours of therapy per day in order to increase her independence with ambulation, activities of 
daily living, and self-care. You also say that the services the enrollee requires cannot be met at a lower level of 
care. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Our 
reviewer also found that the enrollee is not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from August 21, 2021, through 
August 23, 2021, at DRG 281. 
 
You asked the Plan to pay for inpatient services. You say that the medical records support the original coding 
of this claim, and the removal of secondary diagnosis code is unjustifiable. You say that the Plan should 
reinstate the claim as originally billed with DRG 281. The Plan denied your request. The Plan says secondary 
diagnosis code N17.9 and E87.2 are not supported. 
 
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 with secondary diagnosis codes N17.9, defined asacute renal 
failure, unspecified and E87.2, defined as acidosis. 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 inpatient services. Our reviewer says that the documentation does not support secondary diagnosis 
codes N17.9 and E87.2. Our physician reviewer found that while the physician documented the diagnosis of 
acute kidney injury and metabolic acidosis, the documentation does not sufficiently support these conditions as 
being present at the time of this encounter.  
 
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 services provided from August 21, 2021, through August 23, 2021, at DRG 281.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on May 10, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. 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 panel testing was billed with multiple codes. If a single procedure is performed, only one 
code with one unit of service may be reported for the procedure. 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 the gene panel testing provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for automatic external defibrillator (K0606) provided on 
February 7, 2021. 
 
You asked the Plan to pay for automatic external defibrillator. You say that you would like this claim 
reprocessed. The Plan denied your request. The Plan says this claim was received past the 12-month time 
frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for automatic external defibrillator was not filed until March 17, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for automatic external defibrillator (K0606) provided 
on February 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthoses (L1686, L2624) provided on February 16, 
2022. 
 
You asked the Plan to pay for the hip orthoses. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim is missing documentation 
required for payment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical record does not indicate the ordering provider discussed the medical 
necessity of the ordered equipment with the enrollee. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the hip orthoses (L1686, L2624) provided on February 16, 2022.