Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the power operated vehicle. You say that you temporarily need the power 
scooter to be able to grocery shop go to your doctors appointments, pick up your medications and to keep the 
weight off your foot and care for your grandchildren. The Plan denied your request. The Plan says the note 
received does not show that a home assessment was completed and that you do not have the strength to push 
(self-propel) a regular (manual) wheelchair to perform your activities of daily living in your home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 power operated vehicle. Our 
physician reviewer found there is no documentation that your mobility deficit cannot be helped by the use of a 
manual wheelchair. Based on the medical records provided there is no documentation that you can safely 
operate a power mobility device. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power operated vehicle, group 1 standard, patient weight capacity up to 
and including 300 pounds (CPT code K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs device was approved 
by the Food and Drug Administration (FDA) in 2014 but there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
29, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for physician/practitioner services, including doctors office visits. 
 
 
 
 
 
 
 
 You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist office visit provided on March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs coded J3490 provided on March 9, 2022. 
 
You asked the Plan to pay for the drugs. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the services billed are not separately payable. 
 
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, the CPT Code Manual definition of code J3490 is unclassified drugs. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this service was billed within 
a minor procedure with a global surgery period of 10 days. Since this was provided within the global surgery 
period without an appropriate modifier, this service is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan 
does not have to pay for the drugs coded J3490 provided on March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from October 23, 2021, through 
October 28, 2021, at DRG 871. 
 
You asked the Plan to pay for inpatient services at DRG 871. You say that the documentation in the medical 
record clearly supports the clinical diagnoses and you disagree with the removal. You say that the 
documentation supports the DRG as originally billed, and payment of the entire claim should be approved. The 
Plan denied your request. The Plan says principal diagnosis code A41.9 and secondary diagnosis code J96.21 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as sepsis, 
unspecified organism and secondary diagnosis code J96.21, defined as acute and chronic respiratory failure 
with hypoxia. 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 inpatient services at DRG 
871. Our reviewer says that the provided documentation does not support the diagnosis of sepsis or acute and 
chronic respiratory failure with hypoxia. Our physician reviewer found that there was no acute respiratory 
distress or signs of systemic infection causing organ dysfunction.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from October 23, 2021, through October 28, 2021, at DRG 871.
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 medical records provide the need for care. The 
Plan denied your request. The Plan says the records do not show that the enrollee has a clinically complex 
diagnosis or demonstrate the medical complexity to warrant being seen by a rehab doctor at least 3 times a 
week for evaluation of functional and medical goals and progress or require an intensive team (rehab doctor 
and nurse, social worker, and therapists) for their 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 13, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says the claim was 
billed with a GY modifier, which does not meet the Medicare criteria for payment. The Plan also says per the 
denied claim and explanation of benefits, there is no member liability. 
 
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 addition, under Federal law, non-contract 
providers are subject to penalties if they accept more than Original Medicare amounts. 
 
We looked at the file and Medicare rules. In this case, the non-contract provider billed the claim with a GY 
modifier, which does not meet the Medicare criteria for payment. This means that the services cannot be 
reimbursed by Medicare, meaning the Medicare-allowed amount of the services rendered is $0 and the 
provider is not allowed to bill you for these services. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have 
to pay for ambulance services provided on August 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care from September 19, 
2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care until able to walk. The 
Plan denied your request. The Plan says based on Medicare guidelines, the request for approval of continued 
admission in a SNF does not meet the requirements for approval. 
 
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 from September 19, 2022, forward 
based on Medicare guidelines. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care from September 19, 2022, forward.
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 given the member's current care needs, 
the enrollee would benefit from and improve with LTACH care with an expected length of stay greater than 25 
days. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
The plan says the enrollee can safely receive this care in another setting such as SNF. 
 
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 the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 you are being discharged from the hospital and still 
need the care. The Plan denied your request. The Plan says criteria for admission is not met, no documentation 
that the enrollee needs that level of care. Further services can be provided at an alternate level of care. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing 
provided on April 5, 2022. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only 
covered for certain indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the 
cardiac risk assessment genetic screening testing provided on April 5, 2022.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee was admitted with acute hypoxic respiratory failure in the setting of 
pneumonia and pleural effusion. The record indicates that the enrollee has ongoing acute care issues and still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not satisfied.  The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient care provided on April 07, 
2022, to April 09, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were told there would be 
no charges for the services. 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 $150 
copayment for inpatient hospital care. 
 
You have been asked to pay a $150 copayment for the inpatient care. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan.  
 The file shows that you were in the hospital from April 7, 2022, to April 9, 2022. Since there is no copayment 
on the discharge date, you have been asked to pay $150 per day for 2 days of inpatient care, for a total of $300. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient care provided on 
April 07, 2022, to April 09, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided May 20, 2020. 
 
You asked the Plan to pay for the general health panel. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 80050 (general health panel) is considered a 
non-covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (88305 and 88312) provided on May 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you would like the claim reprocessed and paid. The 
Plan denied your request. The Plan says these services were provided OON, were not pre-approved and were 
not referred by an OON provider. 
 
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 the lab services (88305 and 88312) provided on 
May 11, 2022, by an out-of-network (OON) provider.