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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee's medical conditions 
appear stable on outpatient medications with no issues that require a physicians evaluation three or more times 
per week. He may benefit from further therapy but does not require an intensive therapy program in an IRF. The records do not support that a program at an IRF is reasonable and medically necessary at this time. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery coded with 28853, 63047, 122663 and 
22842. 
 
You asked the Plan to pre-approve spine surgery. You say that you have had other surgeries that were paid and 
you smoked then. You don't think this should be denied due to the fact that you smoke. The doctor is willing to 
do the surgery. The Plan denied your request. The Plan says the medical records do not show that spine surgery 
is medically necessary as there is no documentation of a trial and failure of other conservative measures and it 
does not appear that the enrollee has accomplished tobacco cessation. 
 
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 spine surgery. 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 of adequate conservative measures to include physical therapy. The 
enrollee also is a smoker and there is no documentation of adequate smoking cessation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery coded with 28853, 63047, 122663 and 22842.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
whole body (78813). 
 
You asked the Plan to pre-approve a PET scan. You say that the enrollee had a bloodwork which showed that 
there was elevated alkaline phosphatase within both the liver and bones. The Plan denied your request. The 
Plan says the criteria for coverage of a PET scan are not met. The medical records provided do not show that 
the enrollee has had definitive biopsy results in the past. The Plan argues that another exam (78306) may be 
more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that a 
PET scan is not medically necessary for this enrollee at this time. Our physician reviewer found the provided 
medical records do not show that the enrollee has had definitive biopsy results in the past, and there were no 
provided results from other bone imaging such as an x-ray of the pelvis or spine. The enrollee does not have an 
indication for which a PET scan can be covered at this time. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the whole body (78813).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that while the enrollee has a history of atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) supply 
allowance (K0553) provided January 1, 2022. 
 You asked the Plan to pay for the Freestyle Libre Sensor. You say that you are requesting an appeal for this 
denial and have included detailed information to support the medical necessity and reasons why the denial 
should be reconsidered for payment. The Plan denied your request. The Plan says the documentation provided 
does not include one or more of the required records to support payment for this service. 
 
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 a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. The proof of delivery documentation shows that the items were 
shipped on December 23, 2021 and delivered on December 28, 2021. According to the Local Coverage Article 
A55426, the Date of Service should be the shipping date or the delivery date. The Date of Service billed on this 
claim is neither the shipping date nor the delivery date. 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 therapeutic continuous glucose monitor (CGM) supply allowance (K0553) provided January 1, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond 
June 22, 2022. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the continued 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 these services. Our reviewer says that 
the continued services are not medically necessary. Our physician reviewer found the records do not show that 
the enrollee requires intravenous (IV) medications, new tube feedings, ostomy care, or daily complex wound 
care. She does not require skilled nursing services. She has skilled therapy needs but does not require skilled 
therapy on a daily basis. The records document she is functionally limited. There is no documentation of 
progress with therapy or significant decline in her functional status. As a practical matter, the enrollee does not 
require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services beyond June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral imaging 
(D0220), provided by an out-of-network provider on March 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral 
imaging (D0220), provided by an out-of-network provider on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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. 
 
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 81400 is a column II code to column I code 
81413. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. 
 
The documentation submitted on appeal indicates the cardiovascular genetic screening panel was 
initiated by you, the laboratory and not by the enrollee's treating physician nor following a consultation or 
evaluation by the enrollees treating physician. This means the cardiovascular screening/laboratory testing 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 
provided on July 23, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from July 1, 2021, to July 31, 2021. 
 
You asked the Plan to pay for home health services. You say that the claim at issue was billed correctly. The 
Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied on the basis that 30 days of the home health 
benefit have been used and the benefit is exhausted. The Plan has not clearly referenced the rule on which its 
denial is based. The Plan has also not provided evidence that the benefit has been exhausted. It is the Plan's 
responsibility to substantiate its denial. In this case, the denial has not been substantiated, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for home health services provided from July 1, 2021, 
to July 31, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist visit provided on March 15, 
2022. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that you should not need to pay this 
deductible. The Plan denied your request. The Plan says the deductible amount applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to Physician/Practitioner Services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $300 deductible which applies to Physician/Practitioner 
Services. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was 
received on March 15, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a 
specialist visit provided on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
criteria for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. Our reviewer 
also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second computed tomography (CT) scan billed with 
procedure code 72125 for date of service February 17, 2022. 
 
You asked the Plan to pay for a second unit of 72125. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says the medical records do not support billing a second 
unit of 72125 for this date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure 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 a second unit of 72125 Our reviewer says 
that the medical record provided does not support the number of units billed. Our physician reviewer found the 
record shows that the Plan provided payment for one unit of service reported with modifier 25. The 
documentation submitted for code 72125-26-76 was reviewed but does not support an additional unit of 
service. The medical records include four reports of a CT of the cervical spine, without contrast. All four 
document an exam date and time of February 17, 2022, at 12:27AM. All reports are signed by the same 
provider. The first was signed on February 17, 2022, at 1:30, and the remaining three were signed seven minutes later. In this case, all reports document the same exam time, which does not support an additional or 
repeat exam. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a second unit of 72125 have not been met. Therefore, we decided that the Plan 
does not have to pay for a second computed tomography (CT) scan billed with procedure code 72125 for date 
of service February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist visit provided on March 9, 
2022. 
 
You asked the Plan to waive the deductible for a specialist visit. You say that that you had a short visit with this 
provider and should not have to pay the cost share. The Plan denied your request. The Plan says the deductible 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to Physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $250 deductible which applies to Physician/Practitioner 
Services. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was 
received on March 9, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the 
specialist visit provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 10, 2022. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the services provided are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on January 
10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (EEG) provided on February 23, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an EEG. You say that the patients primary care provider is responsible for 
obtaining prior authorization. The Plan denied your request. The Plan says services from non-contracted 
providers are not covered unless preauthorized. 
 
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 an 
electroencephalogram (EEG) provided on February 23, 2022, by an out-of-network (OON) provider.
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 are legally blind and need more care than you 
would get at a nursing home. You also say that the facility requested has a better program for rehabilitation. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information they have 
received about your condition; you do not meet the requirements. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that medically necessary care can be provided in a different 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 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.