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

 
We decided that the Plan does not have to pay for laboratory services (81220, 81329, 81420) provided on 
February 28, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these tests were medically necessary and 
ordered by a physician. The Plan denied your request. The Plan says this claim was submitted with only 
diagnosis code Z34.01 (encounter for supervision of normal first pregnancy, first trimester). These services are 
not a covered screening under Medicare, and no medical reason was provided to support these services as 
necessary. 
 
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. 
 
We looked at the file and Medicare rules. No medical explanation was provided to support that these services 
were reasonable and necessary. The diagnosis code used on this claim indicates that the laboratory services at 
issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory services (81220, 
81329, 81420) provided on February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided by a 
participating provider on January 5, 2022, to February 4, 2022. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the medical criteria for inpatient psychiatric 
hospital services has not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospital services. Our 
reviewer says that these services were not medically necessary. Our physician reviewer found the enrollee does 
not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of 
January 24, 2022 forward and could have been treated in a lesser restrictive setting as he was not showing any 
suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors 
or aggression being cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient psychiatric hospital services provided by a participating 
provider on January 5, 2022, to February 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of home health skilled nursing visits. 
 
You asked the Plan to pre-approve continuation of home health skilled nursing visits. You say that continuation 
of home health skilled nursing visits is medically necessary. The Plan denied your request. The Plan says 
continuation of home health skilled nursing visits is not medically necessary. 
 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 continuation of home health skilled 
nursing visits. Our reviewer says that continuation of home health skilled nursing visits is not medically 
necessary. Our physician reviewer found that based on the documentation provided, the health Plans denial 
should be upheld. The enrollee does not have documented skilled nursing needs. As such, the requested home 
health skilled nursing services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of home health skilled nursing visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continuation of home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an extraction 
(D7140), provided by an out-of-network provider on February 9, 2022, to March 23, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation and an extraction. You say that you did not 
know these services were provided out-of-network. The Plan denied your request. The Plan says services 
provided by an out-of-network provider are not covered. 
 
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 a 
comprehensive oral evaluation and an extraction when the services are medically necessary and reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a comprehensive oral evaluation and an extraction have not been met. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an 
extraction (D7140), provided by an out-of-network provider on February 9, 2022, to March 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing services (90791, 96132, 
96133, 96136, 96137). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that these services are requested so that 
the enrollee may continue to receive social security benefits. The Plan denied your request. The Plan says 
psychological and neuropsychological testing is not covered when it is used for educational or vocational 
purposes that do not establish medical management. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The medical records provided indicate that the enrollee is stable and 
well-controlled on current medications with no desire to change medication or dosage. The records indicate 
that this testing is requested by the enrollees family for the purpose of continuing to collect social security 
benefits. There is no evidence to show that the requested services are medically necessary or reasonable for the 
clinical management of this enrollee. Based on this information, we decided that Medicare rules for coverage 
of neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve neuropsychological testing services (90791, 96132, 96133, 96136, 96137).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine cytopathology (88120) provided on January 25, 2022. 
 
You asked the Plan to pay for urine cytopathology. You say that this service was medically necessary and was 
billed correctly. The Plan denied your request. The Plan says this test was not provided for an enrollee with a 
relevant indication and therefore is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that this assay is performed on urine specimens from 
persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma 
and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer.  
 
We looked at the file and Medicare rules. There is no indication from the record that the enrollee has 
hematuria. Based on this information, we decided that Medicare rules for coverage of urine cytopathology have 
not been met. Therefore, we decided that the Plan does not have to pay for urine cytopathology (88120) 
provided on January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 23, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 23, 2022.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found you are medically stable and 
do not need a physical medicine and rehabilitation physician's close supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or documented. You do not need 3 hours a day x 5 days a week of therapies 
with multidisciplinary approach in an IRF. The documentation does not support the medical necessity due to 
lack of medical complexity and nursing needs, and slow progress for admission to an IRF. While you would 
benefit from physical therapy and occupational therapy, your rehab needs can be safely provided in an alternate 
and lower intensity setting such as in a SNF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on March 23, 2022, and 
March 24, 2022. 
 
You asked the Plan to pay for the drugs. You say that you needed an infusion for quick treatment. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on March 23, 2022, and March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided to the enrollee from February 2, 2022, to 
February 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the determination of whether to use Type of Bill (TOB) 22x or 23x is a function of the type 
of facility in which the beneficiary resides. 
 
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. The plan has not substantiated their denial in this case. The plan is using rules 
that reference skilled nursing facility (SNF) services. The services at issue in this case were home health 
services. The plan has not forwarded a valid denial for these services. Therefore, we decided that the Plan has 
to pay for home health services provided to the enrollee from February 2, 2022, to February 14, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service April 1, 
2022. 
 You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70470. 
 
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 70480 
is a column II code to column I code 70470. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 70480 billed for date of service April 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and services, no transport (A0998) 
provided March 15, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you did not need ambulance services. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on March 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and services, no transport 
(A0998) provided March 15, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of your 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. You were admitted for pelvic and sacral fractures after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that additional 
transportation trips are needed to attend medical appointments. You say that you have an upcoming cataract 
surgery and you have no means of transportation to get to the appointments and back home. The Plan denied 
your request. The Plan says you have exceeded the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visits provided on May 24, 2021, to October 26, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient visits. You say that you want to be reimbursed for the copayments. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 outpatient visits provided on May 24, 2021, to 
October 26, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on May 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 psychotherapy services provided on May 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve psychotherapy visit. You say that you want to stay with the same provider. 
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 provider at issue in this case is not a network provider with the Plan. 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 psychotherapy visit. Our physician reviewer found you are requesting 
authorization of Behavioral Health Treatment Services with a non-contracted/out-of-network provider for the 
dates August 11, 2022, September 15, 2022, and October 6, 2022. You suffered from Bipolar Affective 
Disorder, Unspecified. You had been seen this provider previously in the past. The medical plan had denied 
coverage based on medically necessary claiming that you did not meet criteria for seeing an out-of-network 
provider unless you are being treated for an urgent/emergent situation or the unavailability of a therapist in 
network where the medical plan believes that both of these conditions 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 psychotherapy visit have not been met.  
 
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 psychotherapy visit. Therefore, we decided that the 
Plan does not have to pre-approve psychotherapy visit to be provided by an out-of-network (OON) provider.