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

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the nerves of your 
spine (64635, 64636). 
 
You asked the Plan to pre-approve a radiofrequency ablation (RFA) of the nerves of your spine. You say that 
the service is medically necessary. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must 
be met for coverage. 
 
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 radiofrequency ablation (RFA) of the 
nerves of your spine. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the member did not have 80% pain relieve in each set. 
 
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 radiofrequency ablation (RFA) of the nerves of your spine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the 
nerves of your spine (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a semi-electric hospital bed with side rails (E0260, E0310). 
 
You asked the Plan to pre-approve the semi-electric hospital bed with side rails. You say that the bed is 
medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed with side 
rails. Our reviewer says that the semi-electric hospital bed with side rails is medically necessary. Our physician 
reviewer found the patient require frequent changes in body position and there be a need for immediate changes 
in body position. The patient is quadraparetic secondary to Guillain-Barre syndrome and needs to change body 
position for offloading and to reduce risk of pressure ulceration.  
 
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 semi-electric hospital bed with side rails have been met. Therefore, we 
decided that the Plan has to pre-approve a semi-electric hospital bed with side rails (E0260, E0310).  
 
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: Favorable

 
We decided that the Plan has to pay for the intermediate proton beam radiation treatment services (77523) 
provided from April 5, 2021, through April 11, 2021. 
 
You asked the Plan to pay for the intermediate proton beam radiation treatment services. You say that this 
claim should be reprocessed based on the medical records. The Plan denied your request. The Plan says that the 
number of services billed exceeds the number allowed within the course of treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage specifically because the billed services 
exceed the number allowed. However, the documentation specifically includes an approval letter indicating that 
ten units of proton beam radiation treatment services were approved. Ten units of proton beam radiation 
treatment services were billed. This does not exceed the amount that was originally approved.  Therefore, we 
decided that the Plan has to pay for the intermediate proton beam radiation treatment services (77523) provided 
from April 5, 2021, through April 11, 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: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on December 7, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says that the provider was not certified/eligible 
to be paid for this service on the date in question. 
 
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. 
 
We looked at the file and Medicare rules. In this case, although the Plan originally denied payment because the 
provider was not certified or eligible to be paid, the documentation in the case file indicates the Plan revised 
this decision and found that the provider was eligible to be paid for the services rendered. The case file 
recommended overturning the case, but a decision was not made timely. As a result, it appears that the provider 
is eligible for payment in this scenario as the Plans initial denial was incorrect.  Therefore, we decided that the 
Plan has to pay for the anesthesia services provided on December 7, 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: 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 intense therapy is needed. The Plan denied your 
request. The Plan says IRF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have 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 you 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF admission and services. You say that you live with your daughter 
whose health is bad as well and she is unable to take care of you. The Plan denied your request. The Plan says 
you do not meet criteria for SNF care and can be treated at a lower level of care such as at home with home 
health services, in a long-term care facility or other outpatient setting. 
 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 admission and services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) 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 SNF admission and services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
15, 2021 to June 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, codes Q5001 
and G0157 (home health services) were not billed as the same date of service as code 3AB31. This means these 
home health services were billed incorrectly. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from May 15, 2021 to June 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81286, 81410, 81411, 81413, 
and 81414 provided on June 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81286, 81410, 81411, 81413, and 81414 are not supported in the medical record. 
Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be 
submitted for the panel. Review of the file does not support that only one code was submitted for the panel. 
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 laboratory services coded 81286, 
81410, 81411, 81413, and 81414 provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home COVID test kits. 
 
You asked the Plan to pay for the test kits. You say that testing was strongly recommended. 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 does not pay for OTC items and a home 
COVID test kit is an OTC item. Therefore, we decided that the Plan does not have to pay for home COVID test 
kits.
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 enrollee cannot stand and will need 24-hour care. 
The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic radiology services 
provided on January 12, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic radiology services. The Plan denied your 
request. The Plan says claim number 21175819160 processed correctly and the copayment is the members 
contractual obligation. 
 
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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $40 copayment for outpatient diagnostic radiology services. Outpatient 
diagnostic radiology services 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 copayment for outpatient diagnostic radiology 
services provided on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient hospital admission provided to the enrollee from May 3, 
2021, to May 6, 2021. 
 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that the enrollee was admitted in stable condition, and the expected stay was 
less than two midnights. 
 
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 review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient'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 an inpatient hospital admission provided to the enrollee from May 3, 2021, to May 6, 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 laboratory services coded 88361, 88312, 88305, and 
88104 provided on August 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 88361, 88312, 88305, and 88104 are not supported in the medical record. Specifically, 
these codes have a physician component/technical component indicator of 1. The claim was submitted with a 
place of service 22 (outpatient hospital). The professional interpretation was furnished in the same payment 
locality from where the technical component was furnished.  
 We find that the Medicare rule for payment of this claim has not been met as the professional interpretation of 
a diagnostic test must be separately billed with modifier  26 by the interpreting physician. 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 laboratory services coded 88361, 88312, 
88305, and 88104 provided on August 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation for dialysis. The Plan denied your request. The Plan says that this request exceeds 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 twenty-four (24) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to provide routine transportation above the benefit maximum of 24 trips. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen for the 
enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necesasry. The Plan denied your 
request. The Plan says a new certificate of medical need was not received. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the renewal of a home oxygen concentrator and portable oxygen are considered not medically necessary 
because Medicare criteria are not met. The enrollee has chronic obstructive pulmonary disease. The provider 
Certificate of Medical Necessity is nearly two years old. The only medical records provided are a report of a 
chest computed tomography (CT) scan. There is no recent information indicating continued need for home 
oxygen. 
 
 looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an oxygen concentrator and portable oxygen for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for the SelectMDx testing provided on February 12, 
2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says he provider has not 
provided records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of to pay for the SelectMDx testing 
provided on February 12, 2020. have been met. The non-contract provider has not submitted medical records for review. Without records, it cannot be determined that Medicare coverage criteria have been met.Therefore, 
we decided that the Plan does not have to pay for to pay for the SelectMDx testing provided on February 12, 
2020.