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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee continues 
to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that he would meet criteria for admission to an acute inpatient 
rehabilitation facility. There is no indication that he would require skilled rehabilitation in an IRF, participating 
in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or 
maintain his functional status. He can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 18, 2022. 
 
You asked the Plan to pay for foot orthotics. 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 pay for foot orthotics provided on April 18, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom cup holder (K0108). 
 
You asked the Plan to pre-approve a custom cup holder. You say that you would like the enrollee's wheelchair 
to be repaired so they can resume safe and independent mobility. The Plan denied your request. The Plan says 
this request is not medically necessary because this item is not considered durable medical equipment as it is 
not reasonable and necessary for treatment of illness or injury, it is not used to serve a medical purpose, and it 
is primarily for convenience or comfort. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a custom cup holder (K0108).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for spinal surgery provided to the enrollee on September 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that procedure code 63048-AS is not supported by the medical records submitted. 
 
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 63048 is "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 
each additional vertebral segment, cervical, thoracic, or lumbar (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 services at issue in 
this case were supported by the medical records. Our reviewer found that operative procedure noted a high-
speed burr was used to perform a partial laminectomy of L4 as well as medial facetectomy (primarily removing 
the medial aspect of the inferior articular process, completing the bony decompression.) Then a curette was 
used to release the ligamentum flavum from underneath the lamina of L4 as well (as to work it free into the 
lateral recesses bilaterally and partially release it from the superior aspect of the L5 lamina.) The ligamentum 
flavum was removed, releasing it from the superior margin of the L5 lamina (and then working all the way out 
into the lateral recess obtaining a satisfactory decompression.). Therefore, the records support the use of CPT 
63048. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
spinal surgery provided to the enrollee on September 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that this claim was processed incorrectly, and 
no copayment should be charged. The Plan denied your request. The Plan says the copayment was applied 
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 $165 
copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear 
scans and PET scans, per date of service.  
 
You have been asked to pay $165 for an MRI. An MRI falls in the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies (PA) 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 MRI 
provided on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the perfusion services provided on April 29, 2022. 
 
You asked the Plan to pay for the perfusion services. You say that the services are the standard of care for the 
enrollee's surgical procedure. The Plan denied your request. The Plan says the codes are included in the 
payment made to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
The file shows that the enrollee was an inpatient at the time the services were provided. The facility must 
furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included 
under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this 
information, we decided that Medicare rules for coverage of the perfusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for the perfusion services provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that this provider has been your provider 
for years. You also say that you cannot get a hold of your primary care provider (PCP) office due to long wait 
time. The Plan denied your request. The Plan says this provider is not a part of the Plan network. The Plan also 
says that optometry services are available to the member and can be received from providers in the Plan 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 12, 
2022, to February 8, 2022. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reconsidered. The Plan denied your request. The Plan says the non-contracted provider submitted notice of 
admission (NOA) on March 21, 2022, for the home health care period which started on January 12, 2022. The 
Plan also says that the deadline for submission of the NOA was not within 5 days after the admission date of 
January 12, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAS must submit an NOA to their 
Medicare contractor within 5 calendar days after the start of care date. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the NOA was 
not submitted within 5 calendar days from the start of care date. Therefore, we decided that the Plan does not 
have to pay for the home health care services provided from January 12, 2022, to February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care to help with recovery. 
The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. 
 
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 that the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 99215. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99215 is bundled into payment for code 99205. 
 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 99215 
is a column II code to column I code 99205. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99215 billed for date of service April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual depression screening provided on May 2, 2022. 
 
You asked the Plan to pay for annual depression screening. The Plan denied your request. The Plan says the 
rendering provider is not eligible to perform this procedure. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. The file shows that this provider is an anesthesiologist/pain 
management physician. Based on this information, we decided that Medicare rules for coverage of annual 
depression screening have not been met. Therefore, we decided that the Plan does not have to pay for annual 
depression screening (code G0444) provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthesis components (L5968, L5981, L5301, L5629, 
L5637, L5647, L5781, L5685, L5962, L5620, L5679, L5645, L8417, and L8400). 
 
You asked the Plan to pre-approve prosthesis components. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities. Potential 
functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner, 
considering certain factors. 
 
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 prosthesis components. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the new left lower extremity prosthesis and foot at issue in this case 
meet Medicare's Local Coverage Determination (LCD) - Lower Limb Prostheses (L33787) criteria for 
medically reasonable and necessary. Provided medical records from your physician do not document that your 
present prosthesis has reached its reasonable useful lifetime or has been lost, stolen, destroyed or irreparably 
damaged to meet criteria for replacement as required by Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthesis components have not been met. Therefore, we decided that the Plan 
does not have to pre-approve prosthesis components (L5968, L5981, L5301, L5629, L5637, L5647, L5781, 
L5685, L5962, L5620, L5679, L5645, L8417, and L8400).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided on April 7, 
2022. 
 
You asked the Plan to waive the coinsurance for ostomy supplies. You say that you were told your insurance 
would pay for ostomy supplies at 100% with no copays. 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 20% 
coinsurance for In-network Durable Medical Equipment.  
 
You have been asked to pay a total of $310.20 coinsurance for ostomy supplies ($1,551.03 allowed amount x 
20% coinsurance = $310.20). Ostomy supplies fall within the Durable Medical Equipment (DME) and Related 
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 ostomy supplies provided 
on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a driving apparatus (E1399). 
 
You asked the Plan to pre-approve a driving apparatus. You say that your right leg was amputated, and you can 
only drive with your left leg. The Plan denied your request. The Plan says the requested item is not a covered 
service with your Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a driving apparatus (E1399).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing provided on August 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have Rheumatoid arthritis and a compromised 
immune system. The Plan denied your request. The Plan says that if you get services that are excluded, you 
must pay for them yourself. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. The claim information indicates an advance beneficiary 
notification (ABN) was signed; however, this documentation was not included in the case file. Under Medicare 
rules, this means the lab services is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for the lab testing provided on August 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a computed tomography (CT) scan, 
outpatient clinic visit, and laboratory services provided on February 22, 2022 and May 17, 2022. 
 
You asked the Plan to waive the copayments for a CT scan, outpatient clinic visit and laboratory services. You 
say that you are negatively affected by these additional costs and wonder why you would not be informed of 
these changes by your insurance. The Plan denied your request. The Plan says the copayments applied were 
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 $175 
copayment for Medicare-covered diagnostic radiology services: $125 to $175 copay ($125 at free-standing 
Radiology Clinic; $175 at outpatient hospital). Your contract also says that you must pay a $250 copayment for 
In-Network Medicare-covered outpatient hospital services. 
 
 You have been asked to pay a total of $292.53 ($175 for a CT scan and $117.53 for an outpatient clinic visit 
and laboratory services, which is less than the standard $250 copayment. $175 + $117.53 = $292.53). A CT 
scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. An 
outpatient clinic visit and laboratory services fall 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 copayments for a computed tomography (CT) scan, outpatient clinic visit, 
and laboratory services provided on February 22, 2022 and May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81542) provided on April 27, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, 
providers must submit an appropriate procedure code, 1 unit of service and the appropriate DEX Z-Code. 
 
We looked at the file and Medicare rules. The claim did not include an appropriate DEX Z-code. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81542) provided on April 27, 2022.