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

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis (74176) provided on September 27, 2021. 
 
You asked the Plan to pay for a CT scan of the abdomen and pelvis. You say that the claim denial as a 
duplicate is an error. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT scan of the abdomen and pelvis have not been met. Specifically, the Plan has documented 
that the claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided 
that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and pelvis (74176) 
provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from February 5, 2021, 
to February 6, 2021. 
 
You asked the Plan to pay for inpatient care. You say that these services were medically necessary and pre-
approved, and should be paid. The Plan denied your request. The Plan says one of the diagnoses on this claim 
was billed with an invalid/incorrect Present on Admission (POA) indicator. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 In this case, diagnosis code Z86.16 (personal history of COVID-19) was billed with a POA of Y. This 
diagnosis is on the Medicare POA Exemption List in 2021. That means that this diagnosis should be reported 
with a 1 to signify that this code is exempt from POA reporting. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient hospital care provided from February 5, 2021, to February 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that medical necessity has not been met. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010), a 
prefabricated abutment (D6056) and an implant /abutment supported removable denture for a lower edentulous 
arch (D6111). 
 
You asked the Plan to pre-approve dental services. You say that you cannot obtain your dentures unless you 
have the implant work done. You also say your quality of life is suffering due to not having bottom teeth. You 
are unable to eat the proper foods necessary, and your dentist is unable to place dentures because you have no 
bone structure to hold the dentures in place. You advised that your face is caving in due to the loss of your 
teeth. You would like the plan to reconsider the outcome. The Plan denied your request. The Plan says the EOC 
contains a comprehensive list of all covered dental services. The requested services are not listed and therefore 
not covered. 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of an implant body (D6010), a prefabricated abutment (D6056) and an implant /abutment 
supported removable denture for a lower edentulous arch (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the smoking cessation seminar on October 30, 
2021. 
 
You asked the Plan to reimburse you for the smoking cessation seminar. You say that you would like 
reconsideration because you believed that these services would be covered. The Plan denied your request. The 
Plan says while you are a member of our plan you must use network providers to get your medical care and 
services. 
 The Plan must follow Medicare rules. Medicare rules say that plans may choose the networks of providers 
available to enrollees and may require enrollees to obtain authorization before receiving services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the smoking cessation seminar have not been met. Specifically, the documentation does not 
support that this service was urgent, emergent, approved in advance or rendered by a Medicare-recognized 
provider. Therefore, we decided that the Plan does not have to reimburse you for the smoking cessation 
seminar on October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased an out-of-network vendor on 
November 17, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware that a specific vendor had to 
be used. The Plan denied your request. The Plan says hearing aids purchased from a non-network vendor are 
not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a TruHearing vendor.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids you purchased from an out-of-network vendor, on November 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that you require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in an assisted living facility or a long-term care facility on a part time basis appear appropriate in this 
case. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a foot x-ray provided on November 4, 
2021. 
 
You asked the Plan to waive the copayment for a foot x-ray. You say that this was a post op x-ray after having 
surgery on October 21, 2021. You also say that the billing should have been covered under the surgery. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The Plan also 
says that diagnostic tests, including x-rays are not included in the global surgical package. 
 
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 $15 
copayment for x-ray services.  
 
 According to Medicare diagnostic tests, including x-rays, are not included in the global surgical package. You 
have been asked to pay a $15 copayment for a foot x-ray. A foot x-ray 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 a foot x-ray provided on November 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank physician services (86077) provided on 
November 3, 2021. 
 You asked the Plan to pay for blood bank physician services. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for blood 
bank physician services (86077) provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ResMed Oximetry kit model 37004 (E1399) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the oximetry kit. You say that the DME supplier does not want to order this 
item for you and should have already sent in the order to the Plan. The Plan denied your request. The Plan says 
enrollees must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 
ResMed Oximetry kit model 37004 (E1399) to be provided by an out-of-network (OON) provider.
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 improve his health. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to 
an IRF. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connection between wheelchair controller and 2 or more power seating system motors. 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connection between 
wheelchair controller and 2 or more power seating system motors. You say that the items 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 wheelchair accessories are covered when specific 
criteria are met. 
 
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 expandable controller, harness, and 
electronic connection between wheelchair controller and 2 or more power seating system motors. Our reviewer 
says that the items are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage 
Article: Wheelchair Options/Accessories - Policy Article - A52504 for the requested accessories. Provided 
records document that the enrollee has 3+/5 upper extremity strength with range of motion and function 
reported as within functional limits and he is independent with feeding thus indicating he has adequate upper 
extremity strength and function to operate the wheelchairs power options with their own switches. 
 
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 expandable controller, harness, and electronic connection between 
wheelchair controller and 2 or more power seating system motors have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller, harness, and electronic connection 
between wheelchair controller and 2 or more power seating system motors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a 
hip fracture after a fall and was discharged to skilled nursing. The enrollees medical problems are stable. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
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 that there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 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: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the records provided support the 
need for inpatient psychiatric care. The Plan denied your request. The Plan says the records provided do not 
support that the criteria for coverage of inpatient psychiatric care have been met. The Plan says that the care 
needed can be provided at less restrictive levels. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 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 inpatient psychiatric care. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found it was not expected this 
enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This enrollee 
was compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The 
health plans denial of continued inpatient psychiatric services appears appropriate. It did not appear that the 
services for the dates in question were reasonably expected or medically necessary to improve the enrollees 
condition or for the purpose of diagnosis. The enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of April 1, 2022, forward and could have been 
treated in a lesser restrictive 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator, pulse generator, any type 
(CPT code L8679) and percutaneous implantation of neurostimulator electrode array; peripheral nerve 
(excludes sacral nerve) (CPT code 64555). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says auricular stimulator is not covered by Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Medicare guidance says auricular 
stimulation is not a covered service by Medicare. Therefore, we decided that the Plan does not have to pre-
approve implantable neurostimulator, pulse generator, any type (CPT code L8679) and percutaneous 
implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT code 64555).