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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does 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 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. Medically necessary care can be provided in a different 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 a continuous glucose monitor (CGM) and supplies (K0554, 
K0553) provided on November 16, 2021. 
 
You asked the Plan to pay for a CGM and supplies. You say that this was provided and billed correctly. The 
Plan denied your request. The Plan says this was not ordered by the provider. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pay for a 
continuous glucose monitor (CGM) and supplies (K0554, K0553) provided on November 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on 
February 20, 2022, and February 21, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says medically necessary services could be provided in an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee had a normal physical exam, besides being not cooperative, alert, or 
oriented. The chest x-ray was normal. She was given IV hydration and was admitted to monitor leukocytosis 
and vitals. This could have been done at a lower level of care as she was stable. The documentation did not 
support that the patient would have required hospital care that would have likely crossed 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee on February 20, 2022, and 
February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital 
care is medically necessary. The Plan denied your request. The Plan says the preoperative clearance and 
comorbid conditions suggest that the procedure could initially be performed on an ambulatory/observation 
basis. There is no need to prospectively approve the inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for acute inpatient hospital care has been 
met in this case. Our physician reviewer found you have unilateral primary osteoarthritis of the left hip. Plans 
for total hip arthroplasty were made and approved. This is a request for inpatient services following the 
procedure. However, there was insufficient suggestion from the documentation that you were a high risk 
patient with unstable conditions. There was no indication that you would require hospital services that would 
likely cross 2 midnights for this elective procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing (81455) provided on January 28, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that genetic testing 
procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that CPT code 81455 is non-covered per LCA A56199. 
However, review of this A56199 does not indicate that code 81455 is non-covered. This code is billable when 
51 or greater genes are ordered for molecular biomarkers. The Plan has not provided documentation supporting 
its denial. Therefore, we decided that the Plan has to pay for the genetic testing (81455) provided on January 
28, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 
21, 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 denial of the non-emergent ambulance transport was appropriate given the clinical 
scenario. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that other means of transport (such as stretcher van) were contraindicated for 
this patient on 12/21/21. The documentation does not support that the patient needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance services provided to the enrollee on December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496.  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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service February 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatry services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve psychiatry services to be provided by the requested out-of-network 
provider. You say that the services you are requesting is not available in Plan. The Plan denied your request. 
The Plan says members are contractually required obtain this service from network providers. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve psychiatry 
services to be provided by the requested out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 psychotherapy provided on February 14, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation services. 
 
You asked the Plan to pre-approve wheelchair van transportation services. You say that this is necessary for 
your condition. The Plan denied your request. The Plan says documentation required for wheelchair van 
services was not received. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services. The Plan provides a supplemental benefit beyond what Medicare covers. The Plans supplemental 
benefit states that they pay for wheelchair van medical transportation services when your provider has 
completed a PCS form. 
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. The Plans 
supplemental benefit requires a completed PCS form. The Plan reached out several times to your provider for 
this form and this was not returned. Therefore, we decided that the Plan does not have to pre-approve 
wheelchair van transportation services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 24, 2021, billed 
with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, 81311, 81292, 81295, 81298, 81317, 81321 and 
81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically reasonable 
and necessary. The Plan denied your request. The Plan says these services were not medically necessary and 
were not billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 24, 2021, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, 81311, 81292, 
81295, 81298, 81317, 81321 and 81194.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 7, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing and have submitted supporting 
medical records to support services billed and are requesting a reconsideration of the denied charges. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 an office visit provided on April 7, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0239U) provided on December 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect date of service. 
 
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 0239U is not supported in the medical record. Specifically, the claim was billed with 
date of service December 29, 2021. However, the records show that the specimen was collected on December 
17, 2021. The lab services should be billed with the date the specimen was collected. 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 (0239U) provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 16, 
2022, to February 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the treatment received by the 
member was medically necessary. The Plan denied your request. The Plan says the service was rendered by an 
out-of-network supplier, which requires authorization and there is not one on file. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 a domiciliary or rest home visit provided on 
February 16, 2022, to February 18, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism-correcting intraocular lenses (A-C IOLs) 
provided on February 10, 2022, and February 24, 2022. 
 
You asked the Plan to pay for the A-C IOLs. You say that you would like the Plan's decision for the lens to be 
reconsidered. The Plan denied your request. The Plan says the additional payment for the astigmatism-
correcting lens is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism-
correcting intraocular lenses (A-C IOLs) provided on February 10, 2022, and February 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $621.12 cost share for the abdominal ultrasound, pelvic 
ultrasound and vascular study performed on January 25, 2022. 
 
You asked the Plan to waive the $621.12 cost share for the ultrasounds performed on January 25, 2022. You 
say that you cannot afford to pay the cost share applied. The Plan denied your request. The Plan says this claim 
processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. The Plan contract also says you must pay a $120 copayment for an 
ultrasound. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. At the time this claim was processed, only $164.37 had been applied to 
your deductible. For service 76700 (complete ultrasound of abdomen), $147.67 was applied to your deductible.  
 For service 93975 (complete ultrasound of abdomen and pelvis artery and vein blood flow), $339.51 was 
applied to your deductible. For service 76856 (complete ultrasound of pelvis), the Plans allowance was 
$133.94; $98.45 was applied to your deductible, which satisfied your $750 deductible. The remaining $35.49 
was assessed as a copayment. Therefore, we decided that the Plan does not have to waive the $621.12 
($585.63+$35.49= $621.12) cost share for the abdominal ultrasound, pelvic ultrasound and vascular study 
performed on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on February 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 domiciliary services provided on February 11, 
2022, by an out-of-network (OON) provider.