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

 
We decided that the Plan does not have to pre-approve a wig, any type (A9282). 
 
You asked the Plan to pre-approve a wig. You say that you were told by member services that your Plan 
covered $350 for a wig. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig, any type 
(A9282).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92012) provided on February 10, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you were two years overdue for your eye exam, and 
the providers needed to be re-credentialed. The Plan denied your request. The Plan says this service was 
rendered by an OON provider. The Plan also says that a valid authorization is not on file for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 eye exam (92012) provided on February 10, 
2022 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network outpatient colonoscopy 
provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for an outpatient colonoscopy. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $350 
copayment for outpatient hospital services.  
 
You have been asked to pay a $350 copayment for an outpatient colonoscopy. An outpatient colonoscopy falls 
within the Outpatient Hospital Services 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 an in-network outpatient colonoscopy provided on March 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 6, 2021, to October 17, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records are unable to support shortness of breath while lying flat, within the 
lookback period. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support the 
coding of "Special Care High" in this case. On and 10/9/21 and 10/10/21, it is documented "Does resident 
require head of bed to be elevated to facilitate breathing? every shift for respiratory/ Cardiac Diagnosis NO 
SOB (shortness of breath) noted." The records do not show any evidence of shortness of breath while lying flat. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from October 6, 2021, to 
October 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services (procedure code 73502) provided 
to the enrollee on February 17, 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 the submitted records do not indicate that two separate services were performed. 
 
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 73502 is "Radiologic examination, hip, unilateral, with 
pelvis when performed; 2-3 views." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that a single exam, one view pelvis 
and two views left hip, was done on 2/17/22. There is not a second exam in the records. 
 
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 additional imaging services (procedure code 73502) provided to the enrollee on February 17, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement ultralight weight manual wheelchair. 
 
You asked the Plan to pre-approve the replacement wheelchair. You say that this is medically necessary. The 
Plan denied your request. The Plan says the current manual wheelchair is within the five-year reasonable useful 
lifetime time frame and can be repaired to meet the enrollees mobility and position needs. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime for a wheelchair is 
five years.  
 
The current wheelchair needs repairs, and is within the reasonable useful lifetime period of five years. A repair 
but not a replacement would be covered in this case. Based on this information, we decided that Medicare rules 
for coverage of the replacement wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a replacement ultralight weight manual wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units for ambulance services provided to the 
enrollee on February 6, 2022. 
 
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says the amount of units reported is not correct. 
 
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 443 units of CPT code A0425 are not supported in the medical record. The medical record only supports 250 units of CPT code A0425. Based on this information, we decided that Medicare rules for coverage 
of the additional units have not been met. Therefore, we decided that the Plan does not have to pay for 
additional units for ambulance services provided to the enrollee on February 6, 2022.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be completed at the current facility until more appropriate for 
a lower level of care. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to LTACH is not medically necessary at this time as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 procedure code 99252 billed for date of service December 
17, 2021. 
 
You asked the Plan to pay for procedure code 99252. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 code 99252 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 99252 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99252 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99252 billed for date of service December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 vaccination provided December 1, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccination. You say that this service should be covered. The 
Plan denied your request. The Plan says original Medicare is liable for payment for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that MA organizations should inform their contracted 
providers to submit claims for administration of the COVID-19 vaccine to the CMS Medicare Administrative 
Contractor (MAC) for payment. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Claims for COVID-19 vaccination must be submitted to original 
Medicare. Based on this information, we decided that Medicare rules for coverage of the COVID-19 
vaccination have not been met. Therefore, we decided that the Plan does not have to pay for a COVID-19 
vaccination provided December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, diabetic shoes and inserts (A5500, 
A5514). 
 
You asked the Plan to pre-approve foot orthotics. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, diabetic shoes and 
inserts (A5500, A5514).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can continue to be met at a lower intensity level of care. 
 
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. You 
are medically stable and does not need physical medicine and rehabilitation physician's supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified or documented. At the current functional level, 
you do not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. While you may benefit from continued physical and occupational 
therapy, your rehab needs can be safely provided in a lower intensity and alternate setting. Our physician 
reviewer found that your 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cholecystectomy provided on March 7, 2022. 
 
You asked the Plan to pay for the cholecystectomy. The Plan denied your request. The Plan says per Medicare 
guidelines, this provider specialty does not have the capacity to bill directly for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for a cholecystectomy provided on March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital care provided from 
October 18, 2021, through October 25, 2021. 
 
You asked the Plan to reduce the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $175 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for inpatient hospital care.   
 
You have been asked to pay $875 ($175 copayment x 5 days) for the inpatient hospital care provided. 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 reduce the copayment for the inpatient hospital care 
provided from October 18, 2021, through October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the Keytruda. You say that Keytruda is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74176 and 71250 billed for date of service 
March 25, 2022. 
 You asked the Plan to pay for procedure codes 74176 and 71250. You say that the patient had multiple exams 
on this date of service The Plan denied your request. The Plan says payment for codes 74176 and 71250 are 
bundled into payment for codes 74177 and 71275. 
 
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 codes 
74176 and 71250 are column II codes to column I codes 74177 and 71275. 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 codes 74176 and 71250 billed 
for date of service March 25, 2022.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be completed at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to LTACH is not medically necessary at this time 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 that the requested admission to an IRF does not meet 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found encephalopathy/non-traumatic brain injury is an IRF compliant diagnosis. Clinical documentation shows 
that you have multiple active comorbidities which would require close medical supervision on an inpatient 
basis. Evaluating therapists (PT, OT) both recommend intense therapy and state that you would tolerate it 
significantly. In addition, pre-admission screen states that you will require cognitive therapy thus all factors 
combined IRF criteria has been met and is medically necessary and appropriate. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopy/laparascopy procedures provided on 
February 15, 2022. 
 
You asked the Plan to pay for endoscopy/laparascopy procedures. The Plan denied your request. The Plan says 
per Medicare guidelines, this provider specialty does not have the capacity to bill directly for the services 
rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for endoscopy/laparascopy procedures provided on February 15, 2022.