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

 
We decided that the Plan does not have to pre-approve continue skilled nursing facility (SNF) care after 
January 15, 2023. 
 
You asked the Plan to pre-approve SNF care after January 15, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary.  
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 care after January 15, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found 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 care after January 15, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continue skilled nursing facility (SNF) care after January 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Hydrogel dressing provided on October 
07, 2022. 
 
You asked the Plan to waive the coinsurance for Hydrogel dressing. You say that you cannot afford to pay this. 
The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for durable medical equipment. 
 
You have been asked to pay 20% coinsurance for Hydrogel dressing. This item/service falls within the durable 
medical equipment 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 Hydrogel dressing 
provided on October 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation of a StimQ peripheral neurostimulator 
(PNS) device (64555, 64590). 
 
You asked the Plan to pre-approve an implantation of a StimQ PNS device. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are considered experimental. 
 
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 implantation of a StimQ PNS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is experimental for knee pain. More research is needed to show 
safety and efficacy. 
 
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 implantation of a StimQ PNS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantation of a StimQ peripheral neurostimulator 
(PNS) device (64555, 64590).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Placement surgery (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex Superion Placement surgery. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental 
 
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 a Vertiflex Superion Placement surgery. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is considered experimental and more research is needed to 
show safety and efficacy. 
 
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 Vertiflex Superion Placement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Vertiflex Superion Placement surgery (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs acute care. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's 
medical needs are being met in the current acute setting. The LTACH would add no additional services. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. 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 LTACH services.
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 you are the perfect candidate for inpatient 
rehabilitation. You say you will regress if you go to a SNF. The Plan denied your request. The Plan says the 
IRF care is not medically necessary, and your needs can be met at a lower level of care such as a skilled 
nursing facility. 
 
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 you were admitted for surgical repair of a hip fracture. Your medical problems are 
stable, and there are no complex nursing or rehabilitation needs. You do 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. 
 
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 the orthoses billed for date of service June 21, 2022. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation has been submitted. 
The Plan denied your request. The Plan says the documentation did not support the codes. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The file shows that an ankle-foot orthosis (L1971-RT) and heel stabilizer (L3170-RT) were provided. The 
record does not contain a valid physician order or relevant medical records which support medical necessity for 
the supplies provided in this case. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses billed for date of 
service June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 07, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
September 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274), a comprehensive oral evaluation 
(D0150) intraoral x-rays (D0220, D0230), a panoramic x-ray (D0330) and recementing a crown back into place 
(D2920) for tooth number 13 provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised that the contract with the 
provider had been renewed and the claim would be paid. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewing x-rays (D0274), a comprehensive oral evaluation (D0150) intraoral x-rays (D0220, D0230), 
a panoramic x-ray (D0330) and recementing a crown back into place (D2920) for tooth number 13 provided on 
July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 29, 2022. 
 You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The gene panel was also not billed with a single 
code as required. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like to request reconsideration of the 
denied authorization. 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's needs SNF services to increase 
independence with gait, improve dynamic balance and increase functional activity tolerance. The Plan denied 
your request. The Plan says a SNF admission is not medically necessary. 
 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Peripheral nerve stimulation (PNS) (64555). 
 
You asked the Plan to pre-approve a Peripheral nerve stimulation (PNS). 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 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 a Peripheral nerve stimulation (PNS). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found this procedure is 
considered experimental/ investigational. There is also a lack of documentation of a physical exam and a delineation of what other conservative therapies have been tried. 
 
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 Peripheral nerve stimulation (PNS) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Peripheral nerve stimulation (PNS) (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass lenses provided on September 19, 2022. 
 
You asked the Plan to pay for the eyeglass lenses. You say that your benefit states that the frame cost 
allowance can be used towards the lens. The Plan denied your request. The Plan says the enrollee has exceeded 
the benefit limits.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services in full with a $200 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the benefit allowance towards contact 
lenses on January 4, 2022. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglass lenses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass 
lenses provided on September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this should be covered. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $325 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $325 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital 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 inpatient 
hospital stay provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88108 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 88108. You say that you provided the services to ensure the best 
level of care to the enrollee. The Plan denied your request. The Plan says payment for code 88108 is bundled 
into payment for code 88112. 
 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 88108 is a column II code to column I code 88112. The code at issue 
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 
88108 billed for date of service May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service February 14, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that a modifier is not 
required. The Plan denied your request. The Plan says the codes must be billed with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The records indicate that the specimen was taken at an outpatient hospital facility. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, and 88381. This 
means there is both a professional and technical component for the CPT code(s). In this case, an appropriate 
modifier to indicate the professional component has not been billed. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88341, 88342, 88360, and 88381 billed for date of service February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for The L300 Go System (E0770) and supplies (E1399), 
provided on April 18, 2022. 
 
You asked the Plan to pay for The L300 Go System and supplies. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
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 The L300 Go System and supplies 
have been met. No medical records were provided in this case.. Therefore, we decided that the Plan does not 
have to pay for The L300 Go System (E0770) and supplies (E1399), provided on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an INR blood test provided on June 1, 
2022, by an out-of-network provider. 
 
You asked the Plan to waive the copayment for an INR blood test. You say that you should not owe a cost 
share for the out-of-network INR testing. The Plan denied your request. The Plan says this cost sharing was 
charged 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 50% 
coinsurance for out-of-network Medicare-covered outpatient laboratory, diagnostic procedures, and tests.  
 
 
  You have been asked to pay a coinsurance of $33.17, which is 50% of the allowed amount for an INR blood 
test ($66.34 allowed x 50% = $33.17). This item/service falls within the out-of-network Medicare-covered 
outpatient laboratory, diagnostic procedures and tests 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 INR blood test provided on June 1, 2022, by an out-of-network provider.