Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
implantable loop recorder (ILR) (33285). 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 an implantable loop recorder. 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 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 your 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 an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, implantable loop 
recorder (ILR) (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 laboratory services provided on February 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision exam you had on February 1, 
2022. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for each Medicare-covered vision visit.  
 
 
 
 
 
 
 Review of the file shows that you had a Medicare-covered vision visit on February 1, 2022. You have been 
asked to pay a $50 copayment for the visit. The visit falls within the vision care benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the vision exam you had on February 1, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided on January 10, 2022. 
 
You asked the Plan to pay for these services. You say that this visit should be covered by the Plan. The Plan 
denied your request. The Plan says this is not a Medicare eligible provider, and you did not have prior 
authorization. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services rendered by a provider who is not a Medicare eligible provider. The services at issue in 
this appeal were rendered by a provider who has opted out of the Medicare program. Therefore, we decided 
that the Plan does not have to pay for outpatient mental health care provided to the enrollee on January 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97110) provided on August 21, 
2020. 
 
You asked the Plan to pay for physical therapy services. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that services of a PTA shall not be billed as services 
incident to a physician/NPP's service, because they do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. In this case, the services of a PTA have been billed as services 
incident to a physician/NPP's service. Based on this information, we decided that Medicare rules for coverage 
of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy services (97110) provided on August 21, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit (99284) provided August 20, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that your coding department has reviewed the 
claim and determined that it coded correctly. Please reconsider for payment. The Plan denied your request. The 
Plan says that the diagnoses are not covered. 
 
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 reason to continue to deny. In this case the 
Plan denied that dental services and the diagnosis codes are not covered. However, on page 86 of the Evidence 
of Coverage clearly shows that the enrollee has dental coverage as well as coverage of palliative (emergency) 
treatment for dental pain. The Plan also has not provided any information proving that the diagnosis codes are 
not valid codes. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the emergency 
department visit (99284) provided August 20, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac genetic testing (81401, 81403, 81404, 81405, 
81406, 81407, 81408) provided July 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are the treating physician and you 
ordered a cardio genetics test on 6/29/2021. The Plan denied your request. The Plan says experimental or 
investigational services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at 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 cardiac genetic testing (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an iodine contrast agent for SPECT 
imaging provided on January 11, 2022. 
 
You asked the Plan to waive the coinsurance for the iodine contrast. You say that you should only have the 
$110 copayment for the imaging. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for medical supplies, including chemical agents used in certain diagnostic procedures.  
 
You have been asked to pay $562.70, which is 20% of the allowed amount for the iodine contrast ($2,813.52 
allowed amount x 20% coinsurance = $562.70). The iodine contrast falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an iodine contrast agent for SPECT imaging provided on January 11, 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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in another setting. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for cardiac arrest, respiratory failure, and acute renal failure. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and 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. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pelvic floor electric stimulator purchased on December 10, 
2021, out of network. 
 
You asked the Plan to pay for this equipment. You say that this equipment should be covered by the Plan. The 
Plan denied your request. The Plan says this equipment is not covered when purchased and you did not have 
prior authorization. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract says that 
durable medical equipment requires prior authorization. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does 
not have to pay for a pelvic floor electric stimulator purchased on December 10, 2021, out of network.
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 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 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on June 10, 2022 with sepsis, hematemesis, and a stage IV coccyx decubitis ulcer. He 
is currently undergoing treatment at the acute care hospital (ACH) for a chronic, infected decubitus ulcer. He is 
bedbound and has a tracheotomy and feeding the at baseline. He is not ventilated. There is no evidence that the 
enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the 
same level of care, there is no advantage in transferring the enrollee to the LTACH. The LTACH services are 
not reasonable or medically necessary. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11626 billed for date of service November 
29, 2021. 
 
You asked the Plan to pay for procedure code 11626. You say that the medical records support payment of this 
code. The Plan denied your request. The Plan says Procedure code 11626 is not supported i the medical record. 
. The operative report does not support that a lesion with an excised diameter over 4cm was performed. The 
documentation states total excised diameter is 3.5 cm, which is also the calculated diameter based on the 
measurements given in the operative report of a lesion size of 1.5cm and a margin of 1cm. CPT 11626 is 
denied for coding not supported as there is a more appropriate code available. CPT instructions define the 
excised diameter of a lesion as the "greatest clinical diameter of the apparent lesion plus that margin required 
for complete excision." Specifically, this is equal to the greatest size of the lesion, plus twice the size of the 
narrowest margin. 
 
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 11626 is Excision, malignant lesion including margins, 
scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm.  
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 procedure code 11626. Our reviewer says that code 11626 is 
not supported in the medical record. Our reviewer found the operative report documents: "The total excised 
diameter was 3.5 x 3.5 cm".  In this case, the documentation does not support (per CPT code description) "over 
4.0 cm", and therefore 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 procedure code 11626 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 11626 billed for date of service November 29, 2021.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require an intensive, complex, multidisciplinary 
approach to daily therapy. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for cervical spine 
surgery and was discharged to skilled nursing. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
patient has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF 
admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for pain and gait dysfunction after recent hip surgery. Her medical problems are stable. 
She does not have complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
Additionally, there is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows the services were not rendered in the hospital inpatient setting. Therefore, we decided that the Plan does 
not have to pay for the laboratory services rendered on January 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy services rendered on November 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that condition code 73 or 74 must be billed on Form CMS 
1450 for the calculation of ESRD PPS rates. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 
condition code. Therefore, we decided that the Plan does not have to pay for the chemotherapy services 
rendered on November 4, 2021.