Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT) (G6001). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT should be considered as a first-line option for 
treating NMSC tumors in suitable early-stage patients. The services meet Medicare guidelines for payment 
establishing IGSRT as a standard of care. The Plan denied your request. The Plan says the records show that 
you have a condition or disease that is known to respond well to RT (radiation therapy). This is a type of 
treatment that uses beams of intense energy to kill or shrink diseased cells. The reason this request cannot be 
approved is because picture studies are not supported to guide your type of treatment. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found usually, IGRT is used when critical structures are abutting or in close proximity to the target 
that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can 
be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer 
but not necessary. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need 
has not been established by published data or supported by consensus guidelines (many of which recommend 
against treatment with these devices in general) is not necessary. My decision is unfavorable as billing for daily 
simulations (also requested in this case) or IGRT would not be furnished in accordance with accepted standards 
of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Image Guided Radiation Therapy (IGRT) (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these items cannot be covered as it is not medically necessary to control the three 
approved power options through the joystick (drive interface). 
 
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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested electrical accessories are not medically necessary as the enrollee does have 
use of the upper extremity and can operate and control the power options using the switches that are included in 
the basic wheelchair. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance -air provided on April 02, 2022. 
 
You asked the Plan to waive the copayment for ambulance -air. You say that the nurse called the ambulance for 
you so you shouldnt be charged for 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 a $265 
copayment for Ambulance services. 
 
You have been asked to pay a $265 copayment for ambulance -air. This item/service falls within the 
Ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for ambulance -air 
provided on April 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on May 23, 2022. 
 You asked the Plan to pay for the vision services. You say that you want your 2021 benefits to be applied to the 
2022 service. The Plan denied your request. The Plan says the claim was processed with your 2022 benefits. 
 
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 with a $290 (combined in and out-of-network) benefit toward the 
purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per year) and the enrollee is 
responsible for any amount over $290. 
 
We looked at the file and the Plan's rules. Specifically, the Plan applied the 2022 benefits to the claim. The 
record shows your member responsibility was $0. Based on this information, we decided that the Plan's rules 
for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay 
for the vision services provided on May 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 20, 
2022. 
 
You asked the Plan to waive the copayment for surgery. You say that you have a family history of colon 
cancer, stomach cancer, and GI issues. You think it should be 100% covered by the Plan. 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 $295 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center.  
 
You have been asked to pay $295 copayment for surgery. This item/service falls within the Medicare-covered 
surgery or other services provided to you at an ambulatory surgical center 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 outpatient surgery provided on May 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 13, 2022. 
 
You asked the Plan to pay for the medical services. You say that these claims should be paid. The Plan denied 
your request. The Plan says Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
You ended Medicare Hospice benefits on February 9, 2022. The services in question were provided before the 
end of that month. It should be noted that you re-enrolled in hospice effective February 14, 2022. Therefore, we 
decided that the Plan does not have to pay for medical services provided on February 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on April 27, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you shouldnt have to pay for 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 a $48.91 
copayment for Medicare-covered radiation therapy service. 
 
You have been asked to pay a $48.91 copayment for CT scan. This item/service falls within the Medicare-
covered radiation therapy service 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 
CT scan provided on April 27, 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's needs would be best met in the IRF. 
The Plan denied your request. The Plan says the requested level of care exceeds the enrollee's medical needs. 
 
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 was admitted on October 17, 2022, with vision issues and a fall which 
resulted in a hip fracture. He underwent surgical repair on October 19 and is currently weight-bearing as tolerated. The enrollee is medically stable and does not need physical medicine physician supervision 3 times a 
week in an IRF. There are no acute rehab nursing needs identified or documented. The enrollee does not need 
intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. 
 
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: 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 IRF care is needed for this enrollee's condition. The 
Plan denied your request. The Plan says IRF criteria are not 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 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. 
 
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: 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 it is felt that IRF care would be beneficial. The Plan 
denied your request. The Plan says criteria for this level of care 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for altered mental status and exacerbation of known pulmonary disease. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that the item is necessary. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 3, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found you have a diagnosis of 
chronic obstructive pulmonary disease (COPD), but there are no pulmonary function test results provided. You 
have having chronic CO2 retention, although no arterial blood gas results are provided. You are described as 
having failed bilevel positive airway pressure (BiPAP) because a hospital readmission occurred after it was 
prescribed.  This does not constitute BiPAP failure. BiPAP at higher pressures or with average volume-assured pressure support (AVAPS) has not been tried.  Medicare does not cover a home ventilator when used as 
BiPAP.  
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided on August 26, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that this claim has not been billed with an 
appropriate Core Based Statistical Area (CBSA) code. 
 
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. In this case, the Plan has denied payment stating that the CBSA code billed is 
invalid. However, there is no indication or evidence as to why the code billed, 99903, is invalid for the services 
rendered. Without some kind of citation attesting to the invalidity, the Plans argument cannot be supported. 
Therefore, we decided that the Plan has to pay for the home health services provided on August 26, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, 
MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, 
each specimen (CPT code 83789-59) provided on May 11, 2022. 
 
You asked the Plan to pay for the service. You say that it is found that this claim is under-paid as not all codes 
(83789) were processed at the full amount. The Plan denied your request. The Plan says Modifier 59 is not appropriate as the records do not support a separate and distinct lab service. The Plan states the records do not 
support testing of a non-drug analyte as indicated in the code description. 
 
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 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 service. Our reviewer found the medical record includes 
a urine drug test with specimen validity results. Specimen Validity testing was reported in addition to G0480 
definitive drug testing. Per CPT code description "includes specimen validity testing". Therefore, an additional 
specimen validity test would not be covered. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for mass spectrometry and tandem mass spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, 
QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen (CPT code 
83789-59) provided on May 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
your condition as you are not well enough to be discharged. The Plan denied your request. The Plan says rules 
for SNF care have 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you no longer qualify for SNF coverage. You do not have documented skilled 
nursing needs. In addition, you do not have documented skilled therapy needs. You are currently ambulating 
more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs 
can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 January 6, 2021.