Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Aortography (75625) provided on January 26, 2022. 
 
You asked the Plan to pay for code 75625. You say that the medical records support the billing of code 75625. 
The Plan denied your request. The Plan says the medical records do not support the billing of code 75625. 
 
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 75625 is Aortography, abdominal, by serialography, 
radiological supervision and interpretation. 
 
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 code 75625. Our reviewer says that the medical records do 
not support the billing of code 75625. Our reviewer found the operative report does not describe an abdominal 
aortography procedure. The procedure report documents "Nonselective abdominal aortogram was performed, 
which showed a flow limiting stenosis in right external iliac artery".  Documentation does not include enough information to confirm per NCCI Policy Manual. Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 75625 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Aortography (75625) provided on January 26, 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube.  She is medically stable without any 
acute exacerbations of chronic medical problems. Her physical function is at or near her baseline. She does not 
require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services would 
be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. 
 
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 with a specialist (99203) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with a specialist. You say that you were redirected to see a 
provider in San Diego, however, you are not able to travel far due to your condition. You also say that the 
referral issue has been going on for almost a year and you have not received treatment. The Plan denied your 
request. The Plan says you must receive your care from a network provider. 
 
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 with a specialist (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the claim was processed incorrectly with the facility 
national provider identifier (NPI) and not the rendering provider as it should. The Plan denied your request. 
The Plan says care received from an out-of-network provider will not be covered, and there is no authorization 
on file. 
 
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 office visit provided on January 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 25, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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 Feraheme. Our reviewer says that the 
services are not medically necessary. 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 indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on March 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 domiciliary services provided on March 21, 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 an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that an inpatient admission is 
medically necessary. The Plan denied your request. The Plan says there is no documentation to support the 
expectation that the enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve an inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for coverage of an inpatient hospital 
admission are met in this case. Our physician reviewer found the total shoulder operation is routine and may be safely performed with a 48-hour observational stay. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
January 28, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
services from non-participating 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this equipment is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the requested power scooter is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power scooter. Our reviewer says that 
the enrollee does not meet criteria. Our physician reviewer found the documentation doesn't support why a new 
scooter is required as the previous scooter appears to be equivalent.  Furthermore, she is able to ambulate in the 
home with a walker short distance to accomplish mobility-related activities of daily living. 
 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient hospital care. 
 
You asked the Plan to pre-approve continued inpatient hospital care. You say that it is medically necessary for 
the enrollee to stay inpatient in the hospital. The Plan denied your request. The Plan says the enrollee is ready 
for a lower level of care and no longer requires inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollees 
condition can be managed safely only in the inpatient hospital setting.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued acute inpatient hospital care. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
admitted on 6/30/2022 with lethargy and worsening ulcers in the right hip and toes. As of 7/26/22, the 
enrollees wife remains undecided about palliative care transition and on amputation. Currently, the enrollee is 
to receive IV antibiotics after dialysis and is appropriate to be provided at dialysis center. As of 8/10/22, 
treating MDs document he is ready for a lower level of care. There is no documentation indicating medical 
necessity for continued inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued acute inpatient hospital care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation, per quadrant (D4921) and four (4) 
bone replacement grafts for ridge preservation, per site (D7953). 
 
You asked the Plan to pre-approve dental services. You say that you have type 2 diabetes and if you do not 
have the proper dental treatment, you could have complications with your health, and it puts you at risk to 
worsen your health. Your diagnosis at the moment is periodontal disease infection and compromised teeth. The 
Plan denied your request. The Plan says the procedure codes are not listed and therefore not covered by the 
Plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation, per quadrant (D4921) and four (4) bone replacement grafts for ridge preservation, per site 
(D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement in the amount of $150 for the gym 
membership (S9970) purchased on January 18, 2022. 
 
You asked the Plan to issue additional reimbursement. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you have not provided valid proof of 
payment for additional reimbursement in the amount of $150 for the gym membership purchased. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for additional reimbursement of gym benefits have not been met because the Plan has not 
received valid proof of payment. The case file shows that your original request for reimbursement was for $160 
for a gym membership purchased. The Plan issued payment to you in the amount of $10 as the receipt provided 
to the Plan confirmed you had paid $10 towards this membership. The Plan contract states that enrollees are 
eligible for a reimbursement in the amount of $150 per calendar year towards the cost for a membership in a 
qualified health club or fitness facility with proof of payment.  However, you have not provided valid proof of payment for this additional reimbursement request. Therefore, 
we decided that the Plan does not have to issue additional reimbursement in the amount of $150 for the gym 
membership (S9970) purchased on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure, Genesight 
Psychotropic test (81479) provided February 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you request for reconsideration of the 
original determination and coverage of the GeneSight Psychotropic test as medically necessary. The Plan 
denied your request. The Plan says GeneSight Psychotropic test has not been shown to be useful and is not 
considered medically necessary and appropriate. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this 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 the unlisted molecular pathology procedure, Genesight Psychotropic test (81479) provided February 11, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you an additional $200 for the acupuncture services provided on 
January 7, 2021, through December 14, 2021. 
 
You asked the Plan to reimburse you the additional $200 for acupuncture services. You say that you believe 
you are eligible for a $400 reimbursement. The Plan denied your request. The Plan says that you have been 
reimbursed the maximum amount for the acupuncture services. 
 
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. Specifically, the Plan contract clearly states that you may be reimbursed up to 
$400 for acupuncture services. The Plan has not submitted any evidence to support that you have been 
reimbursed a total of $400. Of note, the documentation submitted supports that you have only been reimbursed 
$200. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial 
has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to reimburse 
you an additional $200 for the acupuncture services provided on January 7, 2021, through December 14, 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 pay for an office visit provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 office visit provided on February 7, 2022, by an 
out-of-network (OON) provider.