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

 
We decided that the Plan does not have to pre-approve an Apolipoprotein (APO) E genotype test (81401). 
 
You asked the Plan to pre-approve an APOE genotype test. The Plan denied your request. The Plan says the 
requested testing will have no impact on the care of the enrollee. 
 
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 APOE genotype test. Our reviewer 
says that the APOE genotype test not considered medically reasonable and necessary in this case. Our 
physician reviewer found APOE variant testing for Alzheimer's Disease is investigational/experimental. No 
clinical role has been established for this testing. Our reviewer found that although positive testing reportedly 
increases the risk of the development of Alzheimer's Disease, the disease can occur in the absence the APOE e4 
allele. Our physician reviewer also found that the requested Apolipoprotein (APO) E genotype test (81401) is 
not medically reasonable or necessary. 
 
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 APOE genotype test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Apolipoprotein (APO) E genotype test (81401).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary 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 epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD requires 3 
months of 50% pain relief. This criterion has not been met and therefore, the request is considered not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on January 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify 
eligibility and to obtain authorization form the enrollee's insurance company. You say the service was 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on January 25, 2022, 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 IRF care is medically necessary so the enrollee can 
get the rehabilitation he needs and get home faster. The Plan denied your request. The Plan says IRF care is not 
medically necessary and the enrollee's needs can be met at a lower level of care such as in a skilled nursing 
facility or on an intermittent basis at home with home health 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. Our 
physician reviewer found that while the enrollee may benefit from additional multiple therapies, including 
physical and occupational therapy, the documentation does not reveal that the enrollee's functional level 
requires this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the open treatment of fractures (25574) and wrist x-ray 
(73110) provided on January 19, 2022. 
 
You asked the Plan to pay for the open treatment of fractures (25574) and wrist x-ray (73110). You say that 
CPT codes 25574 and 73110 are payable as coded. You say that the claim should be reviewed and reconsidered 
for payment. The Plan denied your request. The Plan says the claim was billed with an inappropriate place 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. Medicare rules say that a 
physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a 
minimum, report the inpatient hospital POS code 21. 
 
In this case, the CPT Code Manual definition of code 25574 is open treatment of radial AND ulnar shaft 
fractures, with internal fixation, when performed; of radius OR ulna. The CPT Code Manual definition of code 
73110 is radiologic examination, wrist; complete, minimum of 3 views. 
 
We find that CPT code 25574 and 73110 are not supported in the medical record. Specifically, the outpatient 
POS code was billed but the enrollee was an inpatient at the time the services were received. Based on this 
information, we decided that Medicare rules for coverage of the open treatment of fractures (25574) and wrist 
x-ray (73110) have not been met. Therefore, we decided that the Plan does not have to pay for the open 
treatment of fractures (25574) and wrist x-ray (73110) provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 18, 2022. 
 
You asked the Plan to pay for the office visit. You say that your doctor has been working to alleviate the 
pressure on your sciatic nerve. The Plan denied your request. The Plan says the service or item in question is 
not covered under your contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on February 22, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that the enrollee was seen in the office for a 
Medicare Annual Wellness Exam and a complete physical exam. The Plan denied your request. The Plan says 
no prior authorization was obtained. 
 
 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 did not pre-approve the 
annual wellness visit. We found no exception that would require the Plan to pay for the annual wellness visit. 
The records provided for review do not show that the annual wellness visit was urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the annual wellness visit provided on February 22, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 occupational therapy (OT) sessions. 
 
You asked the Plan to pre-approve OT sessions. You say that the enrollee would benefit from having a tilt in 
space wheelchair with swing away leg rest to decreased anterior leaning with the potential of falling. The Plan 
denied your request. The Plan says based on the clinical notes received, the enrollee's ability to do daily tasks 
has not significantly changed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 OT sessions. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent slow deterioration of the 
enrollee's condition. Our physician reviewer found the patient has already had 10 occupational therapy visits to 
assess her posture and sitting needs. Further occupational therapy is not required to accomplish this. There has 
also been no change in her baseline status, and the patient continues to be dependent with her activities of daily 
living, for which she receives assistance in the long-term care facility she lives in. The documentation also 
indicates that the patient has difficulty following one step commands and therefore cannot actively participate 
in occupational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OT sessions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 occupational therapy (OT) sessions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 21, 2022 by an 
OON provider. 
 
You asked the Plan to pay for laboratory services. You say that these services have been provided by my 
primary doctor. You say you don't understand why you don't change the doctors name on my account so these 
won't get denied. 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 laboratory services provided on February 21, 2022 
by an 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in 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 that the enrollee does continue to require some degree of assistance, but this does not 
necessitate intensive therapy at the level of acute inpatient rehabilitation. 
 
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: Favorable

 
We decided that the Plan has to pay for the inpatient stay provided from January 24, 2022, to January 25, 2022. 
 
You asked the Plan to pay for the inpatient stay. You say that the enrollee had exceeded her two midnights of 
Observation when her physician determined to admit her to inpatient level of care. The Plan denied your 
request. The Plan says that the enrollee did not meet criteria for an 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 pay for the inpatient stay. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found the record does show that at the time of inpatient admission the admitting physician reasonably expected 
that the patient's necessary hospital care (including earlier emergency department and/or observation care) 
would span two 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 the inpatient stay have been met. Therefore, we decided that the Plan has to pay 
for the inpatient stay provided from January 24, 2022, to January 25, 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: 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 
enrollee is medically stable and does not need physical rehabilitation and medicine physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented. At the current functional 
level, 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. While the enrollee may benefit from continued 
physical and occupational therapy the enrollee's rehab needs can be safely provided in a lower intensity and 
alternate setting. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the deluxe frames (V2025), polycarbonate lens 
(V2784), lens (V2100), and prism (V2715) provided on March 2, 2022. 
 You asked the Plan to pay more for the glasses. You say that you needed these glasses due to a medical 
condition. The Plan denied your request. The Plan says you were seen due to getting eyeglasses, and it was not 
related to glaucoma. 
 
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 a $100 (combined in and out-of-network) benefit toward the purchase and fitting of 
eyeglasses per year. 
 
We looked at the file and the Plan's rules. The submitted documentation shows that your eyewear allowance 
was exhausted on March 2, 2022. Based on this information, we decided that the Plan's rules for coverage of 
the glasses have not been met. Therefore, we decided that the Plan does not have to pay more for the deluxe 
frames (V2025), polycarbonate lens (V2784), lens (V2100), and prism (V2715) provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound therapy provided on December 2, 2021, March 9, 
2022, and March 31, 2022. 
 
You asked the Plan to pay for the ultrasound therapy. You say that this therapy is very beneficial to you and 
improves your mobility. The Plan denied your request. The Plan says manual manipulation of the spine to treat 
subluxation of the spine is the only covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for ultrasound therapy provided on December 2, 2021, March 9, 2022, and March 
31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for extracapsular cataract removal surgery 
provided from January 5, 2022, to January 19, 2022. 
 
You asked the Plan to waive the copayment for extracapsular cataract removal surgery. You say that you have 
low income, and these copayments are getting out-of-hand. You also say that the copayments are piling up and 
presenting a very real obstacle to your overall health care. You also say you are only living on your social 
security check and have no money in the bank. The Plan denied your request. The Plan says you were charged 
the correct cost sharing amount. 
 
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 $350 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  You have been asked to pay a total of $700 for two dates of service for extracapsular cataract removal surgery 
($350 x 2 = $700). Extracapsular cataract removal surgery falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 extracapsular cataract removal surgery provided from January 5, 
2022, to January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam provided on March 24, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that this was just a routine eye exam so it 
should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care.  
 
You have been asked to pay $27.37 which is less than the standard $50 copayment for eye exam. Eye exams 
fall within the Vision 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 eye exam 
provided on March 24, 2022.