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

 
We decided that the Plan has to pay for the acute inpatient hospital admission provided from January 7, 2022, 
to January 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you feel your symptoms warranted 
emergency care. You say that your wife and the paramedics thought you were having a stroke. You also say 
that the services should be covered. The Plan denied your request. The Plan says that the inpatient admission 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record shows that the enrollee's condition improved and stabilized after treatment. The 
reviewer also found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital admission provided from January 7, 2022, to January 10, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient physical therapy (PT) and occupational 
therapy (OT) services provided in a skilled nursing facility from June 23, 2021 to June 30, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the PT and OT services. You say that the enrollee was custodial at the time of 
service. You also say that only outpatient therapies are being billed. The Plan denied your request. The Plan 
says prior authorization was not obtained. The Plan says that 
 
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 the outpatient physical therapy (PT) and occupational therapy 
(OT) services provided in a skilled nursing facility from June 23, 2021 to June 30, 2021 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services provided on July 31, 2021. 
 
You asked the Plan to pay for vision services. The Plan denied your request. The Plan says the member has no 
routine benefits only preventative glaucoma screening services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for vision services provided on July 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
by a participating provider on January 12, 2022. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you are allowed two 
exams a year. The Plan denied your request. The Plan says the dental service provided is 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. 
 
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 pay for a 
comprehensive periodontal evaluation (D0180) provided by a participating provider on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), BRCA2 
(BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis (genetic testing for 
cancer) (CPT code 81162). 
 
You asked the Plan to pre-approve the testing. You say that the enrollee has family history of cancer and needs 
the testing done. The Plan denied your request. The Plan says your request is not medically necessary because 
the enrollee's records show they do not have a personal history of cancer. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Review of the records show that the 
enrollee does not have a personal history of cancer. The rules say to be eligible for Medicare coverage, the 
individual being tested must have signs or symptoms of breast (invasive or ductal carcinoma in situ (DCIS)), 
ovarian cancer (including fallopian tube and primary peritoneal cancer), pancreatic cancer, or prostate cancer 
and meet 1 of the criteria below. Genetic testing for a known mutation in a family is a covered service for 
individuals with signs and/or symptoms of cancer. Testing of an unaffected Medicare eligible individual or 
family member is not a covered Medicare benefit.  Therefore, we decided that the Plan does not have to pre-approve BRCA1 (BRCA1, DNA repair associated), 
BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis (genetic 
testing for cancer) (CPT code 81162).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you are currently in Pennsylvania 
and need the therapy for your shoulder after the surgery you had in Florida. The Plan denied your request. The 
Plan says medically necessary care is available in-network. 
 
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 
the physical therapy services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90792 billed for date of service January 11, 
2021. 
 
You asked the Plan to pay for procedure code 90792. You did not provide a specific argument for coverage. 
The Plan denied your request. The Plan says it has already paid for one unit of this code on this date of service 
on another claim.  You have provided no evidence that two units of this code were performed on this date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 90792 are not supported in the medical record. The medical record only 
supports one unit of CPT code 90792. Based on this information, we decided that Medicare rules for coverage 
of procedure code 90792 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 90792 billed for date of service January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77003 and 62322 billed for date of service 
December 7, 2021. 
 You asked the Plan to pay for procedure codes 77003 and 62322. You say that this claim was not paid correctly 
because this was urgent/emergent. The Plan denied your request. The Plan says these codes are not separately 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77003 
is a column II code to column I code 62322. 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.  
 
In this case, we have also confirmed that code 62322 is a column II code to column I code 63047 with a 
modifier indicator of 0. The column II code is therefore not payable. 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 codes 
77003 and 62322 billed for date of service December 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Gel-One. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee. The documentation does 
not support that the enrollee has tried and failed Euflexxa or Synvisc. The documentation does not support that 
Euflexxa, or Synvisc would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. Therefore, the enrollee does not meet step therapy criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on November 4, 2021. 
 
You asked the Plan to pay for the home health care. You say that 1 skilled nursing visit was made during this 
episode. You also say that payment should be made. The Plan denied your request. The Plan says there was no 
exception request was submitted to waive the 5-day requirement for filing the RAP claim due to a circumstance 
beyond your control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, November 4, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (CPT code 64493). 
 
You asked the Plan to pre-approve the injection. You say that you are having trouble eating from the pain and 
if you were to have to wait the standard time it could cause more damage to other parts of your body due to 
lack of nutrition. The Plan denied your request. The Plan says your request is not medically necessary because 
your records show you do not have an absence of untreated radiculopathy, nor do you have a consistent 
positive response to your primary pain with previous facet joint injection, nor are you compliant with your 
current medical treatment instructions. 
 
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 injection. Our physician reviewer 
found the LCD criteria require that there not be other probable pain generators and the initial diagnostic blocks 
have to produce 80% pain relief. You have multiple probable pain generators that have not been addressed and 
the initial diagnostic blocks were NOT positive. Therefore, the request is considered 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT 
code 64493).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tymlos injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Tymlos is on the self-administered drug list and is excluded from 
coverage under Part B. 
 
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 pre-approve Tymlos injection.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia service provided on November 19, 2021. 
 
You asked the Plan to pay for anesthesia. You say that since this claim was not paid in full, you are being held 
responsible for the difference between the charged amount and the Plan's paid amount. The Plan denied your 
request. The Plan says the Plan has paid this claim at the appropriate rate. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of anesthesia have not been met. Specifically, the record indicates that the Plan has paid the Medicare 
Allowed Amount for this service. A Medicare provider should accept the Medicare Allowed Amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to pay for anesthesia service provided on 
November 19, 2021.
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. You say that waiting for a standard service decision 
may seriously jeopardize the enrollee's life, health or the ability to regain maximum function. The Plan denied 
your request. The Plan says they will continue to cover medically necessary acute and critical care at the 
current facility until the enrollee's condition is stable for transfer to an alternate level of care or until the 
circumstances change such that LTACH may be reconsidered. 
 
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 short-term acute care hospital can provide all of the enrollee's present inpatient 
care needs and is receiving an appropriate level of care in the present setting.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (49905) provided on January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 49905 is "Omental flap, intra-abdominal (List separately 
in addition to code for primary procedure)". 
 
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 the services. Our reviewer says that the use of code 49905 is 
not supported by the records provided. Our reviewer found that the operative report documents "We then 
created an omental pedicle flap with omental pedicle vascularly based off the short gastric vessels and the 
gastroepiploic arcade". In this case, CPT 49905 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (49905) provided on January 24, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation of corollary findings. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found you have a history of 
mechanical fall, and have persistent lower abdominal pain and tenderness on physical exam. Bloody stools are 
noted, and there is a history of urinary tract infection. Since the pelvis was not included on the computed 
tomography (CT) exam of March, it is reasonable to do a computed tomography (CT) of the abdomen and 
pelvis, not only to visualize the rectum and sigmoid, but also to look for abdominal fluid, hematoma, and also 
the bladder, as you have urinary tract infection. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) scan of the abdomen and pelvis.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy provided on January 12, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that this service has been covered before. The Plan 
denied your request. The Plan says infrared therapy is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy devices and any related 
accessories is not reasonable and necessary.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Specifically, the file shows that infrared therapy devices 
and any related accessories is not reasonable and necessary. Therefore, we decided that the Plan does not have 
to pay for the infrared therapy provided on January 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve X-ray of the abdomen (74018) provided on January 29, 
2022. 
 
You asked the Plan to pre-approve X-ray of the abdomen. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment.  Therefore, we 
decided that the Plan does not have to pre-approve X-ray of the abdomen (74018) provided on January 29, 
2022.